ࡱ> 7 bjbjUU f7|7|$l^^^^4|RJf f f f !"(l=,QQQQQQQ$\T |V!R--!@!"--!Ri.^^f f {NRi.i.i.-^Rf f Qi.-Qi.Bi.3I"Kf  pAAz.dJKdR0RJ\Wi.WKi.^^^^Physical Requirements Checklist Position Being Analyzed Name (not applicable if vacant):  FORMTEXT       Title:  FORMTEXT       Position No. (not applicable if vacant):  FORMTEXT       Dates Checklist completed:  FORMTEXT       Checklist reviewed with employee (not applicable if vacant):  FORMTEXT       Person Completing Form Name:  FORMTEXT       Title:  FORMTEXT        Part I Indicate with a ( the average amount of time the following are required during a typical day/shift to perform the essential duties of the job (check one category per row). Key: N Never O Occasionally (activity or conditions exist 0 2.5 hours/day) F Frequently (activity or conditions exist 2.5 5.5 hours/day) C Constantly (activity or conditions exist 5.5+ hours/day) Physical ActivityDefinitionNOFCRepetitive MotionRepeating movements of arms, hands, wrists FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX TalkExpress or exchange ideas verbally FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX HearPerceive sound by ear FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX SeeObtain impressions through the eye FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Part II Overall, the essential duties of this position involve the following level of physical activity (check one).  FORMCHECKBOX  Sedentary Occasionally lifting/carrying up to 10 pounds or pushing/pulling small objects Sits most of the time Infrequent to occasional walking or standing  FORMCHECKBOX  Light Frequently lifting, carrying, pushing or pulling up to 10 pounds and/or occasionally lifting, carrying, pushing or pulling up to 20 pounds Frequent walking or standing or sitting most of the time and using arms or legs to push/pull  FORMCHECKBOX  Medium* Occasionally lifting, carrying, pushing or pulling 20-50 pounds and/or frequently lifting, carrying, pushing or pulling 10-20 pounds and/or continuous lifting, carrying, pushing or pulling up to 10 pounds Occasional to frequent walking or standing  FORMCHECKBOX  Heavy* Occasionally lifting, carrying, pushing or pulling 50-100 pounds and/or frequently lifting, carrying, pushing or pulling 20-50 pounds and/or continuous lifting, carrying, pushing or pulling 10-20 pounds Occasional to frequent walking or standing  FORMCHECKBOX  Very Heavy* Occasionally lifting, carrying, pushing or pulling 100+ pounds and/or frequently lifting, carrying, pushing or pulling 50+ pounds and/or continuous lifting, carrying, pushing or pulling 20+ pounds. Occasional to frequent walking or standing *Complete Part III if you selected this category. Part III Indicate with a ( the average amount of time the following are required during a typical day/shift to perform the essential duties of the job (check one category per row). Key: N Never O Occasionally (activity or conditions exist 0 2.5 hours/day) F Frequently (activity or conditions exist 2.5 5.5 hours/day) C Constantly (activity or conditions exist 5.5+ hours/day) Click on field for dropdown menu. Physical ActivityDefinitionNOFCKneelBend legs at knee, come to rest on knees FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Crouch/SquatBend body down and forward, bending legs and spine FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CrawlMove on hands, knees and feet FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX ClimbAscend/descend ladders, stairs, ramps FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Sit FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Stand FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX WalkMove about on foot; average distance per shift  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX StoopBend downward and forward at waist FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX LiftRaise or lower object >10 lbs. From one level to another FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX LiftRaise or lower object >25 lbs. From one level to another FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CarryTransport an object FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX PushPress with steady force, thrust objects forward, downward, outward FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX PullDrag or tug objects FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Turn/TwistMove a body part in circular motion FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX BendBend downward and forward by bending the spine at waist FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX BalanceExceeding ordinary body equilibrium FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX ReachExtend hands and arms in any direction FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX HandleSeize, hold, turn with hands FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Ability to distinguish color FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Other FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Note: Physical requirements include but are not limited to the above list. Instructions: Identify essential functions before completing this checklist. Complete Part I and II for all positions. Complete Part III for positions involving medium, heavy or very heavy physical activity. Save document electronically and/or print and file manually for your records.   jnpptv*,.8jUj\UjUj\UjUjtUjUmHnHujU jU OJQJ^J$jCJOJQJU^JmHnHu>BDFv<@BDFHVXXYf` & F & F & F8:<>FHVxzY# % J     zljOJQJU^JjOJQJU^JjOJQJU^Jj,OJQJU^JjOJQJU^JjDOJQJU^JjOJQJU^J5OJQJ\^J OJQJ^J jTOJQJ^J OJQJ^JjCJUmHnHu jU*# $ % 7 B D F H J $If J K ] HBBBBBB$If$$Iflֈl!X#D%6 r0%64 la  / A HBBBBBB$If$$Iflֈl!X#D%6 r0%64 la   , - . / 0 > ? @ ] ^ l m n o p ~   ~pj OJQJU^Jj0 OJQJU^JjOJQJU^JjDOJQJU^JjOJQJU^JjXOJQJU^JjOJQJU^JjpOJQJU^JjOJQJU^JjOJQJU^J OJQJ^J,A B G ] o HBBBBBB$If$$Iflֈl!X#D%6 r0%64 la   HBBBBBB$If$$Iflֈl!X#D%6 r0%64 la        ! A B P Q R   C D R S T [ \ WXfghnohiwxyjj OJQJU^Jj OJQJU^JB*CJ OJQJ^Jphj~ OJQJU^J5:OJQJ^Jj OJQJU^Jj OJQJU^Jj OJQJU^J OJQJ^JjOJQJU^J3     ! 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