PDQ- Physical Description Questionnaire Data Collection Form

• Department:

• Class Code:

• Class Title:

• Functional Title:

• Date of last JHA

  Date

• New JHA Needed?

  Yes

  No

• Work shift requires other than days?

  Yes

  No

• Does the work shift rotate?

  Yes

  No

• Hours worked: Select one-

  8HRS

  10HRS

  12HRS
• Location:
  Address

• Prepared by:

• Department Site Personnel

Physical Movements

• Bending

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Climbing

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Crawling

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Kneeling

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Reaching

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Squatting

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Stooping

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Simple Grasp

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Firm Grasp

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Fine Movement

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

Motor Sensory

• Employee Must hear Clearly:

• In Noisy Areas

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• On a Radio

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Behind themselves

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Equipment Alarms

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Yes

  No

• Employee must speak clearly enough:

• In Person

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• On the Phone

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• On a Radio

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• On a Cell

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Employee must see well enough to:

• Operate a Motor Vehicle

  Yes

  No

• Operate a Commercial Vehicle

  Yes

  No

• Operate Machinery

  Yes

  No

• Operate a Forklift/Power Industrial Equipment

  Yes

  No

• Distinguish Colors

  Yes

  No

• Have Depth Perception

  Yes

  No

• Have Peripheral Vision

  Yes

  No

Physical Activity

• While sitting (at a desk, table, etc.), employee must be able to lift:

• Above the Head

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• To Shoulder Height

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• To Desk Height

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• While moving around, employee must be able to carry/lift:

• At or Above Head

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• At Shoulder Height

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• At Waist/Desk Height

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• Employee must be able to carry:

• Above Head

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• Wasit to Shoulder

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• Floor to Waist (Approx. 35"-42")

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• Employee must be able to push/pull:

• Above the Head

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• At Shoulder Height

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

• At Waist Height

  Yes

  No

• Activity

  NEC- Necessary

  M- Minor

  N- Never

• Frequency

  Select 0- N/A (0%) 1- Rarely (1% or less) 2- Occasionally (2%-15% of the time) 3- Regularly (16%-40% of the time) 4- Frequently (41%-100% of the time)

  • 0- N/A (0%)
  • 1- Rarely (1% or less)
  • 2- Occasionally (2%-15% of the time)
  • 3- Regularly (16%-40% of the time)
  • 4- Frequently (41%-100% of the time)

• Weight

  Select N- None S- Sedentary (10lbs. Max) L- Light (20lbs. Max; up to 10lbs. frequently) M- Medium (50lbs. Max; up to 20lbs. frequently) H- Heavy (100lbs. Max; up to 50lbs. frequently) V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

  • N- None
  • S- Sedentary (10lbs. Max)
  • L- Light (20lbs. Max; up to 10lbs. frequently)
  • M- Medium (50lbs. Max; up to 20lbs. frequently)
  • H- Heavy (100lbs. Max; up to 50lbs. frequently)
  • V- Very Heavy (Over 100lbs. occasionally; 50+lbs. frequently)

Physical Environment

• Check all boxes that apply:

• Cold

• Confined Space

• Direct Sun

• Driving- Occasional

• Driving- REQUIRED

• Electrical

• Fall Hazard

• Foot Hazard

• Grinding

• Heat

• Ice

• Snow

• Traffic

• Vibration

• Wet

• None

Chemical Environment

• Check all that apply:

• Acids

• Asbestos

• Bases

• Flammables

• Formaldehyde

• Fumes

• Type:

• Gases

• Type:

• Lead

• Vapors

• Type:

• None

Biological Environment

• AIDS

• HEP A

• HEP B

• HEP C

• HIV

• Influenza

• Measles, Mumps, Rubella

• Poisonous Vermin/Pests

• Rabies

• Tuberculosis (TB)

• Tetanus

• Varicella

• Vermin/Pests

• undefined

Noise Level

• Noise level exceeds 85 dBA over an 8 hour TWA?

  Yes

  No

  Don't KNow

Special Work Conditions

• Heights

  Yes

  No

• Fall Protection Required?

• Outdoors

  Yes

  No

• Dust

  Yes

  No

• Noisy Work Areas

  Yes

  No

• Hearing Protection Required?

• Around Moving Equipment

  Select Yes No

  • Yes
  • No

• Extreme Heat

  Yes

  No

• Extreme Cold

  Yes

  No

• Confined Space

  Yes

  No

Personal Protective Equipment (PPE) REQUIRED

• Body

  Yes

  No

• Ear

  Yes

  No

• Hearing Protection Program Required

• Eye

  Yes

  No

• Face

  Yes

  No

• Foot

  Yes

  No

• Safety Shoe Program Required

• Hand

  Yes

  No

• Head

  Yes

  No

Personal Protective Equipment (PPE) Worn

• Gloves

  Yes

  No

• Goggles

  Yes

  No

• Hard Hat

  Yes

  No

• Hearing Protection

  Yes

  No

• Knee Pads

  Yes

  No

• Radiation Badge

  Yes

  No

• Respirator

  Yes

  No

• Appendix D Needed

• Safety Glasses

  Yes

  No

• Safety Harness

  Yes

  No

• Fall Protection Training REQUIRED

  Yes

  No

• Safety Shoes

  Yes

  No

• Safety Shoe Program Required

• Vest

  Yes

  No

Respirator Type

• Any Checked boxes REQUIRE Employee being placed in the County Respiratory Protection Program

• Full Face

  Yes

  No

• Half Mask

  Yes

  No

• N95

  Yes

  No

• PAPR

  Yes

  No

• SAR

  Yes

  No

• SCBA

  Yes

  No

• SCUBA

  Yes

  No

Drug Test

• CDL

  Yes

  No

• County Attorney

  Yes

  No

• Health Care

  Yes

  No

• Sheriff's Department

  Yes

  No

• Safety Sensitive (Any Dept)

  Yes

  No

Comments

• Comments:

SIGNATURES

• Participating Employee:

  Sign

• Participating Facilities Management LCO:

  Sign