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Employee Name: __________________ Hosting Department/Location: _________
Position Name: ____________________ Effective Date: _______________________
Essential Functions: (Health Care Provider: Indicate if the employee can/cannot perform the essential function listed by circling yes or no. Supervisor: List essential job functions.)
______________________________________________________ Yes No
______________________________________________________ Yes No
______________________________________________________ Yes No
______________________________________________________ Yes No
______________________________________________________ Yes No
______________________________________________________ Yes No
______________________________________________________ Yes No
______________________________________________________ Yes No
Physical Requirements: ( Supervisor: Check those that apply to job described above. Health Care Provider: Check yes or no)
|
Requirements
|
Yes
|
No
|
Requirements
|
Yes
|
No
|
| ___ Lifting |
|
|
___ Walking |
___ |
___ |
| ___ Moderate (15-45 lbs) |
___ |
___ |
___ Standing |
___ |
___ |
| ___ Light (up to 15 lbs) |
___ |
___ |
___ Sitting |
___ |
___ |
| ___ Carrying |
|
|
___ Crawling |
___ |
___ |
| ___ Heavy (45 lbs and up) |
___ |
___ |
___ Twisting |
___ |
___ |
| ___ Moderate (15-45 lbs) |
___ |
___ |
___ Pushing |
___ |
___ |
| ___ Light (up to 15 lbs) |
___ |
___ |
___ Stooping |
___ |
___ |
| ___ Reaching above shoulders |
___ |
___ |
___ Kneeling |
___ |
___ |
| ___ Straight pulling |
___ |
___ |
___ Ability to read |
___ |
___ |
| ___ Pulling hand over hand |
___ |
___ |
___ Ability to type |
___ |
___ |
| ___ Dual simultaneous grasping |
___ |
___ |
___ Ability to write |
___ |
___ |
| ___ Operating mechanical equipment |
|
|
___ Hearing |
___ |
___ |
| Specify______________ |
___ |
___ |
___ Speaking |
___ |
___ |
| ___ Operating office equipment |
|
|
___ Climbing stairs |
___ |
___ |
| Specify______________ |
___ |
___ |
___ Simple grasp |
___ |
___ |
| ___ Operating a motor vehicle |
___ |
___ |
___ Repeated bending |
___ |
___ |
| ___ Other:_________________ |
___ |
___ |
|
|
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Additional Recommendations/Restrictions: (Health Care Provider: List if applicable)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Health Care Provider Signature: _______________________ Date: _______________
Health Care Provider Printed Name: ___________________
Approval of Hosting Department: _______________________ Date: _______________
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