Access Medical Physical Demands Evaluation Form
Please fill out the physical demands evaluation form and press submit at the bottom of the form to send it to us. Fields marked with a * are required.

Type of Job Analysis*:
Date Job Analysis was Performed*:
Job Analysis Performed By*:

Client* (Company):
Name* (Adj./Atty.):
Address*:
Address (continued):
City, State*: ,
Zip*:
Telephone*:
Claim #*:
Employee Name*:
Job Title:
Job Location:

Employer / Company*:
Contact:
Employer Address:
Address (continued):
City, State: ,
Zip:
Telephone*:
       
Days / Week: Overtime:
       
Does the employer work eight (8) hours?  
  Yes No How many hours?
       
Meals / Breaks? How Long?
       
Types of equipment, machinery, tools, etc. used on the job:
   
Vehicles or moving equipment driven as part of the job:
   
       

Assuming an eight (8) hour workday this employee would have to spend the following time in each position to complete their job duties, select number of hours for each activity:

Sit hours
Stand hours
Walk hours
Alternate sit/stand/walk hours
Drive hours
       
  Occasionally Frequently Continuously
1. Employee lifts:      
    a. Floor to waist
    b. Waist to shoulder
    c. Shoulder to overhead
       
2. Employee Carries
       
  Occasionally Frequently Continuously
3. Employee must:      
    a. Bend/Stoop from waist
    b. Squat
    c. Climb Stairs
    d. Climb Ladder
    e. Kneel
    f. Balance
    g. Reach
    h. Handle

    i. Finger
    j. Recline

4. Employee works with arms in the following positions:
    Above Shoulder Level Below Shoulder Level
  Right Yes No Yes No
  Left Yes No Yes No

5. Employee uses hands for repetitive actions such as:
    Gross Movements Pushing and Pulling of Arm Control Fine Movements
  Right Yes No Yes No Yes No
  Left Yes No Yes No Yes No

6. Employee uses feet for repetitive movements as in the operating of leg controls:
  Right Yes No
  Left Yes No
  Both Yes No

  Occasionally Frequently Continuously
7. Employee uses head and neck in:      
    a. Flexion
    b. Extension
    c. Rotation
       
    Combined degree of strength:      
         Sedentary Light Medium Heavy Very Heavy

8. Vision
 
  1. Near
  2. Mid-Range
  3. Far
  4. Depth Perception
  5. Visual Accommodation
  6. Field of Vision
  7. Color Vision
 
9. Other Physical Demands
 
 
10. Working conditions
 
 
11. Other comments
 
 
12. Ergonomic Recommendations