YANSAB ATTACHMENT C

I N J U R E D E M P L O Y E E J O B D E S C R I P T I O N

COMPANY EMPLOYEE NAME CONTACT PERSON

ADDRESS DATE REVIEWED

In an 8-hour workday employee is required to (check box):

A. Sit – Number of hours 1 2 3 4 5 6 7 8
B. Stand – Number of Hours
1 2 3 4 5 6 7 8

C. Walk – Number of Hours 1 2 3 4 5 6 7 8

D. Walk – Distance (Minimum)

1-50’ 51-100’ 101-300’

(Minimum) 1-50’ 51-100’ 101-300’

In an 8-hour day employee must: Not At All Occasionally Frequently Continuously

A. Bend/stoop

B. Squat/crouch

C. Crawl

D. Climb

E. Reach above shoulder level

F. Kneel

G. Push/pull
In an 8-hour day employee must lift:
A. Up to 10 pounds (sedentary

B. 11-20 pounds (light)

C. 21-50 pounds (medium)

D. 51-100 pounds (heavy)

On the job, employee uses feet for repetitive movements such as foot controls:
Yes No Yes No No
Right Left Both

On the job, employee uses hands for repetitive actions such as:
Grasping Grasping & Turning Fine Manipulation

A. Right Yes No Yes No Yes No

Left Both

B. Left Yes No Yes No Yes No

Left Both

Job requirements: Yes No

A, Up to 10 pounds (sedentary) X X X Part-time X Full-time

B. 11-20 pounds (light) X X If no, comments: _____________________________________________________

C. 21-50 pounds (medium) X X ___________________________________________________________________

D. 51-100 pounds (heavy) X X ___________________________________________________________________

Prepared By: _______________________________________________________________

H:\000_General\Share\103\Safety\07c-Injured-Job-Description.doc