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RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (Research Corporation of University of Hawaii)

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3.640 RCUH Sick Leave
RCUH Form D-24
Created 05/2004, Revised 03/2011, 10/26/2013
Page 1 of 2
RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
JOB PHYSICAL ANALYSIS FORM
CONFIDENTIAL
Instructions: Please complete this Job/Physical Analysis Form as accurately as possible. This information will be used by an examining
physician to determine any physical limitations or restrictions that may require accommodations and/or modifications to perform the duties of
the job. This information may also be used by an examining physician as a description of the physical demands associated with the job for
post-offer physical examinations.
Employee Name:_______________________________ Project Name:_______________________________________
Job Title:____________________________________________ Employee’s Job Description is Attached for Review
FTE: ____________ Number of Hours Worked Per Day: ___________ Number of Hours Worked Per Week:___________
SECTION 1 - PHYSICAL DEMANDS (to be filled out by Principal Investigator/Supervisor)
Motion
Range of Hours/Day
Performing Motion
Comments
Physician’s Section
ABLE: UNABLE:
Sitting
Standing
Walking
Walking on Uneven
Terrain
Driving
Keyboarding
(typing/data entry)
Bending*
Squatting*
Twisting*
Rotation*
Crawling
Distance:
Reaching
Distance:
Kneeling
Duration:
Lifting/Carrying
10 lbs. or less
11 – 25 lbs.
26 – 50 lbs.
51 – 75 lbs.
76 – 100 lbs.
Over 100 lbs.
Object/Frequency/Distance:
Pushing/Pulling
Distance:
Climbing/Balancing
Distance:
Stair Climbing
Distance:
Physician’s Section: If the employee is released to “LIGHT DUTY”, please indicate:
Full-Time Part-Time *Number of Hours Per Day:_______________ *Number of Hours Per Week: _____________
SECTION 2 – ENVIRONMENTAL CONDITIONS (include comments):
Condition
Condition
Comments
Inside
Outside
Fumes
Odors
Cold
Heat
Noise
Vibration
Altitude
Temperature Extremes
Other
Other
3.640 RCUH Sick Leave
RCUH Form D-24
Created 05/2004, Revised 03/2011, 10/26/2013
Page 2 of 2
SECTION 3 - SUBSTANCE EXPOSURES:
Lead
Gases
Asbestos
Radiation (including Microwave)
Dust
Paints
Epoxy
Other:
Thinners
Solvents
Cutting Oils
Other:
SECTION 4 – REQUIRED PROTECTION USED NOW:
Safety Glasses
Gloves
Hard Hat
Other:
Goggles
Steel-Toe Shoes
Clothing (Type):
Other:
Earplugs
Mask
Respirator (Type):
Other:
SECTION 5 – HAZARDS (based on HAZCOM Program) Attach applicable Safety Data Sheet (MSDS) of hazardous
chemicals/materials.
SECTION 6 - PHYSICAL REQUIREMENTS:
Requirement
Comments
Condition
Comments
Working in Elevation
_______(feet above sea level)
Exposure to Foreign Body (explain)
Breathing (High Altitude)
_______ (feet above sea level)
Vision (select those
that apply in comments
box)
20/40 or better
Depth Perception
Full Field
Color
Breathing (Respirator)
Must meet DOT
Requirements
Provide attachment with
requirements
Hearing
Must hear quiet conversation
Must hear in both ears to
localize source of sound
Special Condition (describe)
SECTION 7 – EQUIPMENT:
Equipment
Comments
Equipment
Hours/Days
Operates Vehicle (type of vehicle):
Power Tools
_________________/________________
Other:
Air Tools
_________________/________________
Other:
Hand Tools
_________________/________________
SECTION 8 - PHYSICIAN'S COMMENTS (Describe any limitations or restrictions –attach additional sheet if necessary):
SECTION 9 – APPROVALS
REVIEWED BY PRINCIPAL INVESTIGATOR (Print Name):______________________________________ PHONE #: ______________
SIGNATURE: ___________________________________________________________________________ DATE: _________________
REVIEWED/ACKNOWLEDGED BY EMPLOYEE (Print Name): ___________________________________ PHONE #: ______________
SIGNATURE: ___________________________________________________________________________ DATE: _________________
I have reviewed Sections 1-7 and Approve / Disapprove (circle one) this individual to perform this job based on the physical examination I performed.
PHYSICIAN'S APPROVAL (Print Name): _________________________________________________________________________
SIGNATURE: __________________________________________________________________________________________________
ADDRESS: ____________________________________________________________________________________________________
PHONE #: _______________________________________________ DATE SIGNED: ______________________________________
The Genetic Information Nondiscrimination Act of 2008 ("GINA") prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an
individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family medical history, the results of an individual's or family
member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or
an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
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RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII (Research Corporation of University of Hawaii)

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Completed 2 November 2020

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