DOA JOB FUNCTION ANALYSIS

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job Characteristics/Environmental Conditions

• Work indoors

• Percent of time (%)

• Work outdoors

• Percent of time (%)

• Chemical hazards

• Radiation exposure

• Atmospheric hazards

• Electrical hazards

• Extreme heat (not weather)

• Extreme cold (not weather)

• Slick walking surfaces

• Concrete walking/standing surfaces

• Uneven walking/working surfaces

• Works alone

• Fall hazards

• Poor lighting

• Wet/humid (not weather)

• Hot materials

• Power tools

• Noise hazards

• Confined spaces

• Traffic exposure

• Vibration

• Sharp tools/materials

• Other

Other condition

• Other condition

Job Category - check one

• Sedentary - exert up to 10 lbs force occasionally and negligible force constantly, standing or walking briefly.

• Light - exert up to 20 lbs force occasionally, <10 lbs frequently, negligible constantly, significant standing/walking.

• Medium - up to 50 lbs occasionally, <20 lbs frequently, <10 lbs constantly.

• Heavy - up to 100 lbs occasionally, <50 lbs frequently, <20 lbs constantly.

• Very heavy - more than 100 lbs occasionally, >50 lbs frequently, >20 lbs constantly

• This work CAN be modified

• How?

• Notes, recommendations, suggestions

• Evaluator

  Sign

• Title