Maximum Force

None

Limited

(0-1 hour)

Occasional

(1-3 hours)

Frequent

(3-6 hours)

Constant

(6-8 hours)

Objects

01-10lbs.

(Sedentary)

x

11-20lbs.

(Light)

x

21-50lbs.

(Medium)

x

51-100lbs.

(Heavy)

x

100 + lbs.

(Very Heavy)

x

Maximum Force

None

Limited

(0-1 hour)

Occasional

(1-3 hours)

Frequent

(3-6 hours)

Constant

(6-8 hours)

Maximum Distance Carried

01-10lbs.

(Sedentary)

x

11-20lbs.

(Light)

x

21-50lbs.

(Medium)

x

51-100lbs.

(Heavy)

x

100 + lbs.

(Very Heavy)

x

Maximum Force

None

Limited

(0-1 hour)

Occasional

(1-3 hours)

Frequent

(3-6 hours)

Constant

(6-8 hours)

Maximum Distance Moved

01-10lbs.

(Sedentary)

x

11-20lbs.

(Light)

x

21-50lbs.

(Medium)

x

51-100lbs.

(Heavy)

x

100 + lbs.

(Very Heavy)

x

None

Limited

(0-1 hour)

Occasional

(1-3 hours)

Frequent

(3-6 hours)

Constant

(6-8 hours)

Comments

Total Reaching

x

Below waist

x

Waist to Shoulder

x

Overhead

x

None

Limited

(0-1 hour)

Occasional

(1-3 hours)

Frequent

(3-6 hours)

Constant

(6-8 hours)

Comments

Sitting

x

Standing

x

Walking

x

Climbing/Balancing (stairs, ladders, other)

x

Operating Foot Controls

x

Rotation of head/neck

x

Flexion (head bend down & head bend back)

x

Bending at the waist

x

Twisting at the waist

x

Kneeling

x

Crouching (squatting)

x

Crawling

x

Lying down (back, side, front)

x

Handling/grasping

x

Forceful Gripping

x

Fine Finger Manipulation

x

Keyboarding/Mouse

x

Repetitive motion (multiple manipulation of same muscle group)

x

High Impact vibratory tools (bucking/riveting)

x

Low Impact vibratory tools (drilling/sanding)

x

Near Acuity: Required

Far Acuity: Required

Depth Perception: Required

Field of Vision: Required

Color Discrimination:  Required

Note Colors: Full Spectrum

20% Inside

80% Outside

Temperature Extremes: All temperature extremes when outside

Noise Level:

Low:

Moderate: x

High: x (occasionally)

Vibration:  Present

Dust: Present

Odors:  Present

Fumes:  Present

Vapors:  Present

Mists: Present

Gases: Present

Chemicals:  Present

Note Types: Possible exposure to commercially available solvents, herbicides, pesticides and other chemicals used in commercial and residential construction and maintenance.

Blood Borne Pathogens Present: May be present

Present

Comments:

Yes

No

Where appropriate: frequency or % of job

COMPREHENSION, REMEMBER & PLAN

Articulate and comprehend information in conversation.

x

Frequent basis

Read, comprehend, and use written materials.

x

Frequent basis

Use technology/instruments/tools & information systems.

x

Frequent basis

Remember spoken instructions.

x

Frequent basis

Remember written instructions.

x

Frequent basis

Remember visual instructions.

x

Frequent basis

Remember simple instructions.

x

Frequent basis

Remember detailed instructions.

x

Frequent basis

Perform repetitive or short-cycle work.

x

Frequent basis

Work under specific instructions.

x

Frequent basis

Completed complex tasks.

x

Frequent basis

ATTENTION & CONCENTRATION

Fine detail:  Regularly deals with data or things requiring attention to minute detail.

x

Frequent basis

Interruptions:  Requires quickly resumed attention after multiple interruptions, or ability to easily shift between tasks.

x

Frequent basis

Sustained Attention:  Requires unbroken lengthy attention to same/similar tasks.

x

Frequent basis

Multitasking:  Job requires ability to attend to more than one activity simultaneously such as typing while answering phones.

x

Frequent basis

Visual or aural distractions:  busy, noisy environment making focusing difficult.

x

Frequent basis

EXECUTIVE FUNCTION

Decision making:  Makes critical decisions potentially affecting costs to company or public safety.($ or lives)

x

Planning:  Responsible for laying-out and planning sequence of work activity.

x

Simple, repetitive, short-cycle tasks:  Must frequently deal with boredom.

x

INFORMATION PROCESSING

Processes highly technical information:  reads, understands and uses complex or highly technical information or computation (calculus, etc.)         

x

Present

Comments:

Yes

No

Where appropriate: frequency or % of job

Integrating Information: Obtains information (reads, hears) from multiple sources, then must be able to synthesize, integrate, and then utilize the information.

x

High productivity or highly speeded work

Meets expectation for high level of output with little “down-time” between tasks.

x

Limited basis

High level visual-spatial reasoning:  Processes information in graphic form.  Perceives 3 dimensional objects from 2 dimensional representations (drawings plans, etc.).

x

ACADEMIC COMPETENCE

High School or equivalency

x

Competence beyond H.S.: AD or BD (circle 1)

x

Graduate level education needed.

How much?  What kind?

x

PSYCHOSOCIAL FACTORS

Works alone:  must work independently, with little oversight or supervision and/or contact with others

x

Frequent basis

Works in close proximity to others:  works in same physical area as others but interaction is either limited or not required.

x

Frequent basis

Frequent &/or extensive interaction with others, such as customers, public or peers (e.g. cashier, receptionist).

x

Frequent basis

Deals with people under adverse circumstances:  deal with people who are angry or confrontational, critiques work of others, gives “bad news” etc.

x

Frequent basis

Deals with people under pressure of time or numbers (Customers with construction or code problems)

x

Limited basis

Teamwork:  Works as integral part of team, must cooperate with others, divide tasks, integrate output, and put team goals, ideas or plans before ones’ own.

x

Frequent basis

ATTENDANCE

Maintain predictable and reliable attendance.

x

Frequent basis

Be punctual.

x

Frequent basis

Take rest periods at set times or only times determined by breaks in job responsibilities.

x

Only as conditions and circumstances allow.

Adjust to a flexible schedule of work days or shifts.

x

Limited basis