The Americans with Disabilities Act (ADA) was signed into law July 26,1990. Title I of the Act governs
employment issues and became effective July 16, 1992. The purpose of Title I of the Act is to ensure that
qualified individuals with disabilities are protected from discrimination on the basis of their disability. The
ADA provides equal opportunities for qualified individuals with disabilities who can perform the “essential”
functions of a position with or without reasonable accommodation. As part of our compliance with this
legislation, the ADA Questionnaire will gather specific information regarding the essential physical activities
and mental requirements as well as essential and non-essential duties required for this position.
The information on the ADA Questionnaire should be completed by someone who is totally familiar with all the
physical and mental aspects of this position and any specific equipment or devices used in this job.
A carefully drafted, comprehensive position / job description (PDQ or JDQ) is the best piece of documented
evidence submitted to a court identifying the essential functions of the job. In addition, a job description should
be an especially helpful tool to be used when recruiting and filling a vacant position and a historical overview of
often overlooked aspects of individual jobs. Please elaborate on any areas you think need additional
information or clarification to describe these aspects of the position.
Compliance with the ADA requires us to categorize the duties or tasks assigned to this position as being
“essential” or “non-essential” job functions. Please indicate whether the duties listed on the PDQ or JDQ are
ESSENTIAL [E] or NON-ESSENTIAL [N] using the following guide:
Those duties and responsibilities that an individual in this position must be able to perform unaided or with the
assistance of reasonable accommodations. A job function may be considered essential for several reasons,
1) Job tasks that are fundamental and not marginal, or the reason the position exists is to perform that
function, OR
2) The number of employees available to perform that function is limited; OR
3) The function may be so highly specialized that the person in the position is hired for his / her
expertise or ability to perform the particular function.
Those job functions than an employer may transfer or reassign to other individuals or that are not
required to be performed by an individual with a disability.
Questions regarding the ADA Physical / Mental Requirements Questionnaire should be directed to the office
that provided the form to you (either Human Resource Services or Affirmative Action). Please return the
completed Questionnaire to the office that provided the form to you.
SUPERVISOR: Initials to indicate concurrence:
Check the physical requirements necessary to perform the essential duties of the position (refer to the most
recent job description—PDQ or JDQ)
PHYSICAL REQUIREMENT DESCRIPTION. Indicate time / amount where required
Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on
narrow, slippery, or erratically moving surfaces
Bending and Stooping: Bending body downward and forward by bending spine at the waist.
(_____ hours per day)
Climbing: Ascending or descending ladders, scaffolding, ramps, poles, and other devises using feet and
legs and/or hands and arms. Body agility is emphasized
Climbing Stairs: Ascending or descending stairs to gain access to a building or to move from one floor
to another
Crawling: Moving about on hands and knees or hands and feet
(_____ hours per day)
Light Carrying: Physically transporting items weighing less than 15 pounds from one location to
Moderate Carrying: Items weighing 15 to 44 pounds
Heavy Carrying: Items weighing 45 pounds and over
Fingering: Picking, pinching, typing, or otherwise working primarily with fingers rather than with the
whole hand or arm
Grasping: Applying pressure to an object with fingers (including thumb) and palm
Kneeling: Bending legs at knees to come to rest on one or both knees
(_____ hours per day)
Light Lifting: Raising objects under 15 pounds from a lower to a higher position or moving objects
horizontally from one position to another
Moderate Lifting: Objects 15 – 44 pounds
Heavy Lifting: Objects 45 pounds and over
Mobility Requirement: Enough to __________________________________________________
(Provide examples)
Pulling Hand over Hand: Using upper extremities to exert force in order to draw, drag, haul, or tug
objects in a sustained motion
(_____ hours per day)
Pushing: Using upper extremities to press against something with steady force in order to thrust
forward, downward, or upward
(_____ hours per day)
Reaching above shoulder: Extending hand(s) and arm(s) in any direction
Repetitive motion: Substantial movements of the wrists, hands, and/or fingers for sustained periods of
Sitting: Particularly for sustained periods of time
(_____ hours per day)
Walking: Moving about on foot, particularly for long distances.
(_____ hours per day)
Visual Requirement: Enough to _________________________________________________________
(Examples: Able to see and read PC screens; detect color coding, read fine print, and/or normal type size print)
Hearing Requirement: Enough to:_________________________________________________
(Examples: able to detect specific noises, proper equipment operation; understand what clients are saying in
normal conversation)
Other Physical Requirements: Describe:
Check each of the mental abilities that are required to perform the essential functions of this position. Please
comment in the space provided to elaborate or further explain this position’s mental capability needs.
Ability to understand, remember, and apply oral and/or written instructions or other information
Ability to understand, remember, and communicate routine, factual information
Ability to understand complex problems and to collaborate and explore alternative solutions
Ability to understand opposing points of view on highly complex issues and to negotiate and integrate
different viewpoints
Ability to organize thoughts and ideas into understandable terminology
Ability to organize and prioritize own work schedule on short-term basis (longer than one month)
Ability to organize and prioritize work schedules of others on short-term basis
Ability to organize and prioritize work schedules of others on long-term basis
Ability to apply common sense in performing job
Ability to make decisions which have moderate impact on immediate work unit
Ability to make decisions which have significant impact on the immediate work unit and monitor impact
outside immediate work unit
Ability to make decisions which have significant impact on the department’s credibility, operations, and
Ability to understand and follow basic instructions and guidelines
Ability to complete routine forms, use existing form letters and/or conduct routine oral communication
Ability to compose letters, outlines, memoranda, and basic reports and/or to orally communicate technical
Ability to communicate with individuals utilizing a telephone; requires ability to hear and speak effectively
on phone
Ability to express or exchange ideas by means of the spoke word, communicating orally with others
accurately, loudly, and quickly
Ability to make informal presentations, inside and/or outside the organization. Speaking before groups
Ability to compose materials such as detailed reports, work-related manuals, publications of limited scope
or impact, etc., and/or to make presentations outside the immediate work area
Ability to formulate complex and comprehensive materials such as legal documents, authoritative reports,
official publications of major scope and impact, etc., and/or to make formal presentations
No mathematical ability is required
Ability to count accurately
Ability to add, subtract, multiply, divide and to record, balance, and check results for accuracy
Ability to compute, analyze, and interpret numerical data for reporting purposes
Ability to compute, analyze, and interpret complex statistical data and/or to develop forecasts and
computer models
Additional comments regarding mental capability requirements:
List all computers, peripherals, and
other hardware required to
perform this job:
List all computer software
required to perform this job:
List all office machines required
to perform this job:
List any other machines (including
heavy equipment) required to
perform this job:
List all tools involving
manipulation that are required to
perform this job:
List all vehicles that must be
operated to perform this job:
Indicate any additional pertinent information about the requirements for this job that have not been
previously addressed on this questionnaire:
Revised 08/10
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