N=Never or Not Required

R=Rarely

O=Occasionally

F=Frequently

C=Continually

0%

0 hours

1-25%

0-2 hours

26-50%

2-4 hours

51-75%

4-6 hours

76-100%

6-8+ hours

PHYSICAL

Frequency

N

R

O

F

C

MOBILITY/STABILITY

Sit

x

Stand

x

Walk

x

Jog/Run

x

Crawl

x

Balance

x

POSTURE

Rotate/Tilt/Twist Neck

x

Reach Any Direction

x

Push/Pull

x

Twist at the Waist

x

Bend at the Waist

x

Step Backward

x

Bend at the Knees

x

Squat

x

Kneel

x

Climb (Ascend/Descend)

x

DEXTERITY

Grasp/Hold/Write with Hand

x

Type/Pinch/Pick with Fingers

x

Flex/Rotate/Screw/Supinate/Pronate Wrist

x

STRENGTH (Lift/Carry/Lower)

0-10 lbs

x

11-20 lbs

x

21-50 lbs

x

51-99 lbs

x

100+ lbs

x

COMMUNICATION

Frequency

N

R

O

F

C

Written

x

Verbal

x

Hearing Acuity

x

Visual Acuity

x

ENVIRONMENTAL

Frequency

N

R

O

F

C

Operate Moving Machinery

x

Operate Power Tools

x

Drive Vehicles/Pedal

x

Exposure to Weather Conditions

x

Exposure to Chemical Hazards

x

Exposure to UV Radiation

x

Exposure to Electrical Hazards

x

Exposure to Biological Hazards

x

Exposure to Respiratory Conditions

(Allergens/Dust/Smoke/Fumes/Odors/Gases/Grease/Oil)

x

Exposure to Loud Noises/Vibration

x