Fillable Exposure To Health Risks Physical Demands Form (Page 2 of 7) in pdf

Exposure To Health Risks Physical Demands Form Page 2

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PHYSICAL DEMANDS SECTION

Name_____________________________ DOB____________________

A. Physical Demands

B. Time

C. Specifics

D. Key Job Tasks and

Lifting: Fill in finishing height. Enter realistic day to day

Task times vary but

Comments

approximate (as close as

weight lifted.

List the 3 most frequent or

Essential function to

possible) how many

Floor (0”), Waist(~29”), Chest (~54”), Above (>54”)

critical activities & any

perform job?

hrs/mins is each specific

Carrying: Distance covered in one effort.

comments that will explain how

one 8

i.e. Loading dock to counter – 40 feet

the activities are completed.

task performed in

Push/Pull: Equipment i.e. cart, dolly, etc.

Example: lifts food cans from

hour day.

Team: More than one person doing activity together.

counter to shelf.

i.e – 1-2hours or 30 min.

Height of Lifting:

Lifting -

□ Yes □ No

From:

Weight

Finishing Height

Individual Team

Floor

________

_______(lbs)

□

Waist

________

_______(lbs)

□

Chest

________

_______(lbs)

□

Above

________

_______(lbs)

Individual

Team

□ Yes □No

Carrying -

Object:

If load weight varies

indicate maximum realistic

Distance Carried:

load required to perform

________________ feet

likely job duties.

Load Weight:

________________ (lbs)

Pushing/Pulling - □ Yes □ No

Surface:

Flat □

Smooth □

Some bumps □ Uneven □

If load weight varies

Equipment push/pull:_____________

indicate maximum realistic

Approx’ Wheel diameter___________ inches

load required to perform

Maximum Distance: ______________ feet

likely job duties.

Load Weight:

________________ lbs

Climbing -

□ Yes

□ No

Ladder (A-Frame) _________________lbs

Realistic weight being

Stairs

_________________lbs

Testing will be performed only on above methods.

lifted.

Testing heights and weights will be performed with safety of employee in mind using NIOSH guidelines. If load and method of movement is

considered to place employee at risk of injury, testing will be adjusted and documented.

Exposure To Health Risks Physical Demands Form Page 2

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