PHYSICAL DEMANDS FORM – YARD/SAWMILL

*. In an * hour workday, employee must: (Circle full capacity of each activity) a. Sit No. 1 2 3 4 5 6 7 8

b. Stand No. 1 2 3 4 5 6 7 8

c. Walk No. 1 2 3 4 5 6 7 8

2. Employee’s job requires:

Not at all Occasionally Frequently Continuously

a. Bend/Stoop X

b. Squat X

c. Crawl X

d. Climb height X

e. Reach above

shoulder level

X

f. Crouch X

g. Kneel X

h. Balance X

i. Push/Pull X

3. Employee’s Job requires he/she carry:

Never Occasionally Frequently Continuously

a. Up to 10 lbs. X

b. 11-24 lbs. X

c. 25-34 lbs. X

d. 35-50 lbs. X

e. 51-74 lbs. X

f. 75-100 lbs. X

Note: In terms of an 8 hour workday, “Occasionally” equals 1% to 33%;

“Frequently”, 34% to 65%; “Continuously”, 67% to 100%. PHYSICAL DEMANDS FORM CONTINUED

4. Employee’s Job requires he/she lift:

Never Occasionally Frequently Continuously

a. Up to 10 lbs. X

b. 11-24 lbs. X

c. 25-34 lbs. X

d. 35-50 lbs. X

e. 51-74 lbs. X

f. 75-100 lbs. X

5. Job requires employee use feet for repetitive movements as in operating foot controls: 6. Job requires employee use hands for repetitive actions such as: Simple Grasping Firm Grasping Fine Manipulating

Right Yes No X Yes No Yes No

Left Yes No X Yes No Yes No

7. Employee’s job requires:

Yes No Comments

a. Working on unprotected heights X

b. Being around moving machinery X Lift trucks, saws, planers, etc. c. Exposure to marked changes in

temperature and humidity

X

d. Driving automotive equipment X

e. Exposure to dust, fumes and gases X

Right Left Both

Yes No Yes No X Yes No

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