CHECK APPROPRIATE BOX FOR EACH OF THE FOLLOWING ITEMS TO BEST DESCRIBE THE EXTENT OF THE SPECIFIC ACTIVITY PERFORMED BY THE STAFF MEMBERS IN THIS POSITION PHYSICAL DEMANDS
On-the-job time is spent in the following physical activities Show the amount of time by checking the appropriate boxes below. ¾ Amount of Time ¾ None up to 1/3 1/3 to 1/2 2/3 and more Stand: X Walk: X Sit: X Talk or hear: X Use hands to finger, handle or feel: X Push/Pull: X Stoop, kneel, crouch or crawl: X Reach with hands and arms: X Taste or smell: X This job requires that weight be lifted or force be exerted. Show how much and how often by checking the appropriate boxes below. ¾ Amount of Time ¾ None up to 1/3 1/3 to 1/2 2/3 and more Up to 10 pounds: X Up to 25 pounds: X Up to 50 pounds: X Up to 100 pounds: X More than 100 pounds: X This job has special vision requirements. Check all that apply. X Close Vision (clear vision at 20 inches or less) X Distance Vision (clear vision at 20 feet or more) X Color Vision (ability to identify and distinguish colors) X 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) X Depth Perception (three-dimensional vision; ability to judge distances and spatial relationships) X Ability to Adjust Focus (ability to adjust eye to bring an object into sharp focus) q No Special Vision Requirements Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. WORK ENVIRONMENT This job requires exposure to the following environmental conditions. Show the amount of time by checking the appropriate boxes below. ¾ Amount of Time ¾ None up to 1/3 1/3 to 1/2 2/3 and more Wet, humid conditions (non-weather): X Work near moving mechanical parts: X Fumes or airborne particles: X Toxic or caustic chemicals: X Outdoor weather conditions: X Extreme cold (non-weather): X Extreme heat (non-weather): X Risk of electrical shock: X Work with explosives: X Risk of radiation: X Vibration: X The typical noise level for the work environment is: Check all that apply. q Very Quiet q Loud Noise q Quiet q Very Loud Noise X Moderate Noise Hearing: q Ability to hear alarms on equipment q Ability to hear client call q Ability to hear instructions from physician/department staff REPETITIVE MOTION ACTIONS ¾ Number of Hours ¾ Repetitive use of foot control 0 1-2 3-4 5-6 7+ A. Right only X B. Left Only X C. Both X Repetitive use of hands A. Right only X B. Left Only X C. Both X Grasping: simple/light A. Right only X B. Left Only X C. Both X Grasping: firm/heavy A. Right only X B. Left Only X C. Both X Fine Dexterity A. Right only X B. Left Only X C. Both X
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