Job Analysis
Instructions: File this form as an attachment to a WC-240
EMPLOYER
SCHEDULE
WORK PACE
Self-Paced?
Incentive-Paced?
Machine-Paced?
WEIGHT
LIFTING
FREQUENCY
Never
Occasional
(up to 1/3 of the time)
(up to 1/3 of the time)
Frequent
(1/3 to 2/3 of the time)
(1/3 to 2/3 of the time)
Constant
(over 2/3 of the time)
(over 2/3 of the time)
OBJECTS
Lowest Point Lift/Lower
Height
Heighest Point Lift/Lower
Height
CARRYING
Max. Distance Carried
PUSH/PULL MAX FORCE
Max. Distance Moved
Posture/Movements
Max. Consec.
min/hours
min/hours
Total Daily Hours
Position Change Optional?
Further Description
Sitting
Standing (In Place)
Walking
Use Arm/Leg Controls
Never
Occasional
(up to 1/3 of the time)
(up to 1/3 of the time)
Frequent
(1/3 to 2/3 of the time)
(1/3 to 2/3 of the time)
Constant
(over 2/3 of the time)
(over 2/3 of the time)
List Equipment, Machines, Tools, Vehicles Used
Special Considerations (Environmental Conditions, Vision, Hearing, Height)
To be filled out by the authorized treating physician
1. Employee can perform this job while taking medications as prescribed.Yes No