For the following pages, refer to the following activity codes to fill in the blank:

NA - Not Applicable (No Explanation Of Area Is Needed)

A - Minor - Activity or condition exists less than 20% of work
time.

B - Moderate - Activity or condition exists 20-60% of work time.

C - Major - Activity or condition exists 60% or more of work
time.

Example:

Physical Demand Checklist:

1. Strength Activity Code Reason for the rating
b. Lifting____50_lbs ________B Lift boxes for shipping, weighing 50 lbs. 2 hours per day.

Enter the letter code from the previous list that best identifies your activity in this area.
Also explain why you have rated each activity as you did.

FORM II: Physical & Mental Qualifications



----------------------------+------------------------------------------
| Give reasons why you have coded each
PHYSICAL DEMANDS CHECKLIST | selection A, B, C. NA does not require
| an answer. List all pertinent facts.
----------------------------+-------------------------------------------
1.STRENGTH |
a.Standing___10__% of shift |
Walking___5___% of shift |
Sitting____85__% of Shift |
Activity|
Code |
b.Lifting________lbs ____A__| Very little lifting.
Carrying_______lbs ____A_| Very little carrying.
Pushing________lbs ____A__| Very little pushing.
Pulling________lbs ___ A_ | Very little pulling.
2.CLIMBING |
Stairs ____A__ | Few stairs in normal work area.
Ladders ____NA_ |
|
BALANCING ____A | Only balancing is sitting/walking.
3.STOOPING ____A__ | Very little stooping.
KNEELING ____A__ | Very little kneeling.
CROUCHING ____A___ | Very little crouching.
CRAWLING ____A_ | No crawling.
TURNING/TWISTING ____A__ | Very little turning/twisting.
BENDING AT WAIST ____A___ | Very little bending at the waist.
|
4.REACHING ____A___ | Some reaching at desk.
HANDLING ____NA___ |
FINGERING ____NA___ |
FEELING ____A___ | Very little feeling.
THROWING ____NA___ |
EYE-HAND COORDINATION ____B___ | Some required to operate office equip.
FOOT-HAND-EYE |
COORDINATION ____A___ | Very little required.