Employer'S Statement Form Page 2
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Working environMent inforMation – Is this employee exposed to one or other of the following? (check as applicable):
rarely
not often
often
very often
constantly
never
n/a
Noise
Dust
Vibration
Outdoor work
Hazardous machinery
Hazardous products
Other (Please specify)
PHYsicaL effort inforMation – To what extent must this employee do as follows? (check as applicable):
rarely
not often
often
very often
constantly
never
n/a
Position
Sit
Stand
Walk
Crouch on knees
Crawl
Stretch arms above shoulder height
Stretch arms below shoulder height
Climb up and down stairs
effort
Lift up
Push
Raise
Pull
Move objects
Conduct repetitive movements
Can this employee change position if needed?
q yes q no
Percentage of time per day:
sitting: _______ %
standing: _______ %
walking: _______ %
Is this employee required to lift heavy objects?
q yes q no
Maximum weight is normally:
q 0 - 5
q 10 - 15
q 20 - 25
q 30 - 35
q 40 - 45
q 50 and over ( q pounds or q kilograms)
If this employee’s work involves repetitive movement, please specify: ____________________________________________________________
Percentage of total working time: _______ %
Limb(s) solicited: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Repetitive movement with: q dexterity (e.g.: keyboard speed) or q physical effort (e.g.: assembly line)
Pace is:
q fixed (e.g.: feed machine) or q variable
PsYcHoLogicaL effort detaiLs – To what extent must this employee resort to? (check as applicable):
rarely
not often
often
very often
constantly
never
n/a
Memory and comprehension
Sustained concentration
Social interaction
Adaptation
stateMent
i hereby certify that the information provided hereinabove is, to the best of my knowledge, true and complete.
Name of company: _________________________________________________________________________________________________________________
Address: __________________________________________________________________________________________________________________________
Telephone: (______) ________________ Fax: (______) ________________ E-mail: _____________________________________________________________
Name of signatory: _______________________________________________________ Title: ____________________________________________________
Signature: ______________________________________________________________ Date: ____________________________________________________
day / m on th / ye a r
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Parent category: Business