Supervisory: ☐Yes ☒ No |
☒Exempt ☐ Nonexempt |
Pay Type: |
If yes: ☐ Employees ☐ Contact Wkrs |
If exempt: ☐ Professional ☐ Admin
☐ Executive ☐ Other |
☐Salaried ☐Hourly ☒Stipend |
WORKING ENVIRONMENT: |
SELDOM |
OCCASIONAL |
FREQUENT |
SELDOM |
OCCASIONAL |
FREQUENT |
||
EXTREME COLD OR HEAT |
X |
VISUAL ACUITY: Near/Far |
x |
|||||
HEIGHTS |
X |
HEARING |
x |
|||||
NOISE |
X |
SPEECH |
x |
|||||
DRIVING |
X |
EYE/HAND COORDIN. |
x |
|||||
WALKING/Uneven Surfaces |
X |
TRAVEL: |
||||||
WORKING ALONE |
X |
Local |
x |
|||||
WORK WITH OTHERS |
X |
National |
x |
|||||
MOVING HEAVY ITEMS: |
SELDOM |
OCCASIONAL |
FREQUENT |
OPERATING MACHINERY: |
||||
LIFTING/LOWERING |
Over 30 lbs |
Over 20 lbs. |
0-20 lbs. |
COMPUTER |
x |
|||
LIFTING OVER SHOULDER |
Over 30 lbs |
Over 20 lbs. |
0-20 lbs. |
COPIER |
x |
|||
REACHING OVER SHLDER |
Over 30 lbs |
Over 20 lbs. |
0-20 lbs. |
MOUSE |
x |
|||
CARRYING |
Over 30 lbs |
Over 20 lbs. |
0-20 lbs. |
TELEPHONE |
x |
|||
PUSHING/PULLING |
Over 30 lbs |
Over 20 lbs. |
0-20 lbs. |
OTHER (please list) |
||||
PULLING |
Over 30 lbs |
Over 20 lbs. |
0-20 lbs. |