EMPLOYEE: ______________________________________ SSN: _____________________________
JOB TITLE: _______________________________________________________________________________
PHYSICAL DEMANDS OF JOB:
LIFTING: Never
0
30 1 hr
Rarely
1 5
1hr-21/2hr
Occas.
6 33
21/2-5hr
Freq.
34 66
5-8 hr
Cont.
67 100
Sedentary: up to 10#
Light: 10 20
Medium: 20 50#
Heavy: 50 100#
Very Heavy: 100+#
CARRYING:
Sedentary: up to 10#
Light: 10 20#
Medium: 20 50#
Heavy: 50 100#
Very Heavy: 100+#
STANDING:
WALKING:
SITTING:
PUSHING/PULLING:
CLIMBING:
KNEELING:
CRAWLING:
STOOPING/BENDING:
TWISTING:
GRASPING:
FINGERING:
REACHING:
DRIVING:
ENVIRONMENTAL HAZARDS:
Moving parts:
Electrical shock:
High, Exposed Places:
Radiant energy:
Toxic chemicals:
Fumes:
Dampness:
Heat:
Cold:
Gases:
Noise:
Dust:
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_______________________________ _______________________
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______________________________ ___________________
PHYSICAL DESCRIPTION OF WORK SITE:
SUMMARY JOB DESCRIPTION: IF SO, WHY?
IS JOB MODIFIABLE? YES/NO IF SO, WHY?
RECOMMENDATION AFTER JOB ANALYSIS:
HRM APPROVAL: _____________________________________ ____________________
Date
TITLE: _____________________________________________
_____ As recommended. ______ With the following modifications:
******************************************************************************************
I concur that the above accurately describes the physical demands of my position duties.
Employee: _____________________________ Date: _______________________
******************************************************************************************
Based upon the information provided in this Job Analysis, I feel it is within the patient’s ability to perform these
duties.
PHYSICIAN’S SIGNATURE DATE
I do not feel that the patient is able to perform the duties of this position because of the following reasons:
PHYSICIAN’S SIGNATURE DATE
ADA/VRA:1/97
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