UNITED 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’

(
M
(Minimum) a 1-50’ 51-100’ 101-300’
x
i
m
u
m
)

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
Left Both
Right

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

/conversion/tmp/scratch/436612898.doc
 UNITED ATTACHMENT C

Job requirements: Yes No

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

 Part-time  Full-time If no, comments: _____________________________________________________

B. 11-20 pounds (light)   ___________________________________________________________________

:
If no comments
___________________________________________________________________

_________________________ Prepared By: _______________________________________________________________

____
C. 21-50 pounds (medium)  
D. 51-100 pounds (heavy)  

/conversion/tmp/scratch/436612898.doc