Physical Environmental Mental Demands Form printable pdf download

Physical/Environmental/Mental Demands Form (PEM)

This form is intended to assist departments in determining the demands of positions and in recognizing any accommodations which may

be necessary per the provisions of the Americans with Disabilities Act (ADA) of 1990. Keep a copy of the completed form with the Job

Description in the employee’s personnel file. For vacant positions, be sure to indicate any outstanding demands or any demands unusual

for the classification on the Job Vacancy Listing (JVL). After completing this form, submit it to Human Resources with the JVL.

Job Title:

________________________________

Department: ________________________________

Physical Demands

hours at one time

total hours per day

(without accommodations)

<½

½-1

1-2

2-4

1-2

2-4

4-6

6-8

sitting

walking

standing

bending neck

twisting neck

bending waist (forward or sideways)

twisting waist

squatting (crouch or sit on one’s heels)

climbing ______________________

kneeling

crawling

repetitive* movement: Hand

Ø simple grasping

1 hand___ both___

Ø power grasping

1 hand___ both___

Ø fine manipulation

1 hand___ both___

Ø pushing/pulling

1 hand___ both___

reach above shoulder height

reach below shoulder height

move items weighing up to 10 lbs.

move items weighing 11-25 lbs.

move items weighing 26-50 lbs.

move items weighing 51-75 lbs.

move items weighing 76-100 lbs.

move items weighing over 100 lbs.

driving

repetitive* movement: Foot

Other __________________________

*constant for at least 15 minutes

Environmental Demands (check all that apply)

A. Extreme cold (below 32

)