Employee Physical Profile Form - A-One Plus
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1EMPLOYEE PHYSICAL PROFILE
FORM
I
certify that I am able to meet the following physical profile requirements for my position.
(please print name)
Measurement Criteria:
1. Lifting:
Light (must be able to lift 5-20 pounds).
Moderate (must be able to lift 20-50 pounds).
Heavy (must be able to lift weights in excess of 50 pounds).
2. Pushing:
Light (must be able to push light objects such as an empty wheelchairs).
Moderate (must be able to push objects such as an occupied wheelchair).
Heavy ( must be able to push an occupied motorized wheelchair).
3. Pulling:
Light (must be able to pull light objects such as an empty wheelchair).
Moderate (must be able to pull objects such as an occupied wheelchair).
Heavy (must be able to pull an occupied motorized wheelchair).
4. Mobility:
No mobility required for this position.
Moderate mobility.
Continual mobility.
5. Stair Climbing:
No climbing.
Must be able to climb stairs.
Must be able to climb ladders. Must be able to climb ramps.
Must be able to climb ramps.
6. Standing:
No standing required.
Short duration (less than 10 minutes without a break).
Moderate duration (10-30 minutes without a break).
Continual (more than 30 minutes without a break).
7. Sitting:
Intermittent sitting.
Prolonged sitting.
8. Squatting:
It is not necessary to be able to bend at the knees in order to perform this job.
It is necessary to be able to bend at the knees in order to perform this job.
9. Stooping:
Ability to bend at the waist is not necessary in order to perform this job.
Ability to bend at the waist is necessary in order to perform this job.
10. Reaching:
No reaching required.
Must be able to reach above shoulder level.
11. Fine motor skills:
It is not necessary to have use of fine motor skills in order to perform the job duties.
It is necessary to have use of fine motor skills in order to perform the job duties.
12. Sight:
It is not necessary to have vision in order to perform this job.
It is necessary to have vision in order to perform this job.
13. Communication:
Not required to communicate with all staff or the general public.
Must be able to communicate effectively with staff and the public.
14. Other:
Must be able to provide maximum assistance when transferring patients.
Other physical specifications required to do this job.
By my signature I certify that I am able to perform the above physical requirements in order to perform my job duties.
Employee Signature:
Date:
Witness Signature:
Date:
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Parent category: Medical