Transcription of C545 EMPLOYER - PHYSICAL DEMANDS ANALYSIS
1 C-545 REV AUG 2019 Page 1 C545 EMPLOYER - PHYSICAL DEMANDS ANALYSISC laim Number:Worker s Surname:Given Name:Initial:Job Title:Hours per shift:Shifts per week/shift rotation:Company NameEmployer ContactTelephone NumberManual Handling Tasks Description of objects handled [Weight/force (lb)]FREQUENCY OF WORKDAY / SHIFTNot RequiredRare1 5% Occasional6 33% Frequent34 66%Constant67 100%Place the heaviest weight / force handled into the appropriate Low Level LiftingBox of 24 bottles of water (18 lb), bag of cement mix (66 lb)66 lb18 lbLow Level LiftingWaist Level LiftingAbove Shoulder LiftingFront Carry Side Carry Shoulder PushingSweeping floors, securing loads with a snipe, moving a loaded skid with a pallet jackHeavyforceLight forcePushing(stationary and walking)Pulling(stationary and walking)Positional TasksDescription of activity completedCheck appropriate Forward BendingShoveling gravel, sweeping floors, picking up garbage, washing vehicles with pressure washerSitting/Driving(type of seat/chair)
2 Forward BendingTrunk RotationStandingWalking - Outdoors(terrain/distance)Walking - Indoors(surface/distance)Climbingstairsl addersOther Climbing (stools, equipment, etc.)3 2 %2; ('021721 $% 7 - 6 )$; C-545 REV AUG 2019 Page 2 Low Level Activity(kneeling/squatting/crouching)Ab ove Shoulder Level ReachingBelow Shoulder Level ReachingHand UseDominantNon-DominantForceful GrippingDominantNon-DominantEnvironmenta l Factors(indoor/outdoor)List Heaviest and Most Frequently Handled Materials:( , bag of sugar 44 lb)List Most Frequently Handled Tools and Equipment:( , grinder, hammer, cordless drill)xxxxxxxxxxxxxxxxPrimary Job Duties:(What are the essential job functions?)xxxxSeparate the above Primary Job Duties into Specific Tasks within each Strength Level: (What level of strength would be required for each task?)Limited:Exerting up to 5 kg (11 lb) , computer work, answering phones, filing, :Exerting up to 10 kg (22 lb) , sweeping floors, painting, operating forklift, :Exerting up to 20 kg (44 lb) , off-loading trucks, shoveling snow, patient transfers, :Exerting over 20 kg (44 lb) , securing loads with tie down bar; breaking down pallets of bagged cement mixAlternate Job Duties:(Which would be possible work tasks outside of the regular job tasks)xxxxxxPrinted Name:Date: Signature.
