Fillable WORKING CONDITIONS DEMAND FORM Mental (California State University, Los Angeles)

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WORKING CONDITIONS DEMAND FORM Mental (California State University, Los Angeles)

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4
WORKING CONDITIONS DEMAND FORM
A. Physical
How much on-the-job time is spent in the following physical
activities? Show the amount of time by checking the appropriate
boxes below.
None Under 1/3 1/3 to 2/3 Over 2/3
1. Stand ............................. ■■ ........... ■■ ............■■ .......... ■■
2. Walk.............................. ■■ ........... ■■ ............■■ .......... ■■
3. Sit ................................. ■■ ........... ■■ ............ ■■ .......... ■■
4. Use hands to finger,
handle, or feel ...............
■■ ........... ■■ ............ ■■ .......... ■■
5. Reach with hands
and arms .......................
■■ ........... ■■ ............■■ .......... ■■
6. Repetitive use of
feet/hands .....................
■■ ........... ■■ ............ ■■ .......... ■■
7. Climb or balance .......... ■■ ........... ■■ ............■■ .......... ■■
8. Stoop, kneel, crouch,
crawl .............................
■■ ........... ■■ ............■■ .......... ■■
9. Talk or hear ................... ■■ ........... ■■ ............ ■■ .......... ■■
10. Taste or smell ................ ■■ ........... ■■ ............ ■■ .......... ■■
11. Test/Analyze ................. ■■ ........... ■■ ............ ■■ .......... ■■
12. Drive motor vehicles
and operate equipment ..
■■ ........... ■■ ............■■ .......... ■■
13. Operate scientific
equipment and
machinery ..................... ■■ ........... ■■ ............ ■■ .......... ■■
B. Weight
Does job require that weight be lifted or force exerted?
Ye s
■■ No ■■
Check the appropriate boxes. (In measures of time)
None Under 1/3 1/3 to 2/3 Over 2/3
1. Up to 10 lbs. ................. ■■ ........... ■■ ............ ■■ .......... ■■
2. Up to 25 lbs. ................. ■■ ........... ■■ ............ ■■ .......... ■■
3. Up to 50 lbs. ................. ■■ ........... ■■ ............ ■■ .......... ■■
4. Up to 75 lbs. ................. ■■ ........... ■■ ............ ■■ .......... ■■
5. Up to 100 lbs. ............... ■■ ........... ■■ ............■■ .......... ■■
6. More than 100 lbs. ........ ■■ ........... ■■ ............■■ .......... ■■
Attach addendum on the specific job duties that require the
physical effort selected above.
C.
Vision
Does this job have special vision requirements? Yes ■■ No ■■
Check all that apply.
1.
■■ Close vision (clear vision at 20 inches or less)
2.
■■ Distance vision (clear vision at 20 feet or more)
3.
■■ Color vision (ability to identify and distinguish colors)
4.
■■ Peripheral vision (ability to observe an area that can be
seen up and down or to the left and right while eyes are
fixed on a given point)
5.
■■ Depth perception (three-dimensional vision, ability to
judge distances and spatial relationships)
6. ■■ Ability to adjust focus (ability to adjust the eye to bring an
object into sharp focus)
7.
■■ No special vision requirements.
D.
Mental
Indicate the extent of mental effort required for the job.
Check the appropriate box. (In measures of time)
None Under 1/3 1/3 to 2/3 Over 2/3
1. Direct others ................. ■■ ........... ■■ ............ ■■ .......... ■■
2. Write ............................. ■■ ........... ■■ ............ ■■ .......... ■■
3. Use math/calculations... ■■ ........... ■■ ............■■ .......... ■■
4. Work at various
tempos ..........................
■■ ........... ■■ ............ ■■ .......... ■■
5. Concentrate amid
distractions ...................
■■ ........... ■■ ............■■ .......... ■■
6. Remember names ......... ■■ ........... ■■ ............ ■■ .......... ■■
7. Remember details ......... ■■ ........... ■■ ............ ■■ .......... ■■
8. Make decisions ............. ■■ ........... ■■ ............ ■■ .......... ■■
9. Work rapidly ................. ■■ ........... ■■ ............ ■■ .......... ■■
10. Examine/observe
details ...........................
■■ ........... ■■ ............■■ .......... ■■
Make notes on the specific job duties that require the mental effort
selected above.
E.
Environmental
How much exposure to the following environmental conditions
does this job require? Show the amount of time by checking the
appropriate boxes below.
None Under 1/3 1/3 to 2/3 Over 2/3
1. Wet or humid conditions
(non-weather) ...............
■■ ........... ■■ ............■■ .......... ■■
2. Work near moving
mechanical parts ...........
■■ ........... ■■ ............■■ .......... ■■
3. Work in high,
precarious places ..........
■■ ........... ■■ ............■■ .......... ■■
4. Fumes or airborne
particles ........................
■■ ........... ■■ ............■■ .......... ■■
5. Toxic or caustic
chemicals ......................
■■ ........... ■■ ............ ■■ .......... ■■
6. Outdoor weather
conditions .....................
■■ ........... ■■ ............■■ .......... ■■
7. Extreme cold
(non-weather) ...............
■■ ........... ■■ ............■■ .......... ■■
8. Extreme heat
(non-weather) ...............
■■ ........... ■■ ............■■ .......... ■■
9. Risk of electrical
shock.............................
■■ ........... ■■ ............■■ .......... ■■
10. Work with
explosives .....................
■■ ........... ■■ ............■■ .......... ■■
11. Risk of radiation ........... ■■ ........... ■■ ............ ■■ .......... ■■
12. Vibration ....................... ■■ ........... ■■ ............ ■■ .......... ■■
F. Noise
How much noise is typical for the work environment of this job?
Check the appropriate level below.
1.
■■ Very quiet (examples: forest trail, isolation booth for
hearing test)
2. ■■ Quiet (examples: library, private office)
3.
■■ Moderate noise (examples: business office with computers
and printers, light traffic)
4. ■■ Loud (examples: large earth-moving equipment)
5.
■■ Very loud (examples: jack hammer work, front row
at concert)
Make notes on the specific job duties that are affected by the
environmental conditions selected above.
5
HOW SHOULD A FUNCTION BE CONSIDERED?
The EEOC indicates that in “identifying an essential function to determine if an individual with a
disability is qualified, the employer should focus on the purpose of the function and the result to be
accomplished, rather than the manner in which the function presently is performed. An individual with a
disability may be qualified to perform the function if an accommodation would enable this person to
perform the job in a different way, and the accommodation does not impose an undue hardship.”
Examples In a job requiring use of a computer, the essential function is the ability to access, input and
retrieve information from the computer. It is not “essential “that a person in this job enter information
manually, or visually read the information on the computer screen. Adaptive devices or computer
software can enable a person without arms or a person with impaired vision to perform the essential
functions of the job.
A job that requires objects to be moved from one place to another should state that essential function.
The analysis may note that the person in the job “lifts 50-pound cartons to a height of 3 to 4 feet and
loads them into truck-trailers 5 hours daily, “but should not identify the “ability to manually lift and load
50-pound cartons” as an essential function unless this is the only method by which the function can be
performed without causing an undue hardship.
If a job requires mastery of information contained in technical manuals, this essential function would be
“ability to learn technical material, “ rather than “ability to read technical manuals. “People with
visual and other reading impairments could perform this function using other means, such as audiotapes.
A supervisor may structure operations to be carried out by a “team” of workers. Each worker performs
a different function, but every worker is required, on a rotating basis, to perform each function, In this
situation, an the functions may be considered to be essential for the job, rather than a single function
that any one worker performs at a particular time.
WHO IS ENTITLED TO REASONABLE ACCOMMODATION?
Qualified individuals with a disability who can perform the essential function of a job, with or without
reasonable accommodation. ADA protection only extends to persons with disabilities, as defined by the
statute and by EEOC regulations. Not all health or medical conditions are ADA disabilities, however, and
frequently an employer will need to determine whether a particular applicant is a person with an ADA
disability before determining accommodation obligations.
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WORKING CONDITIONS DEMAND FORM Mental (California State University, Los Angeles)

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Completed 22 July 2020

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