ESSENTIAL JOB FUNCTIONS
Please put a check mark by each of the following essential job functions that you are able to perform on a repetitive or prolonged basis as a part of your job. Please note by checking that you can perform an essential job function does not necessarily mean you will be required to perform that essential job function on an assignment.
| Bend |
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Sit |
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| Climb |
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Stand |
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| Crawl |
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Stoop |
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| Drive |
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Sweep |
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| Hand Motion |
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Twist |
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| Hearing |
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Walk |
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| Manipulate Small Parts |
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Wrist Motion |
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Can you:
| Work in a confined space? |
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| Work in a dust or pollen filled environment? |
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| Work with hazardous chemicals? |
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| Stand for an 8- or 10-hour shift? |
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| Work in a hotter than normal environment? |
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| Work in a colder than normal environment? |
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| Work outdoors? |
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| Lift up to 70lbs continuously? |
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| If no, how much can you lift? |
| Continuously: |
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| Occasionally: |
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If you did not check an item or answered no to any of the items above, or if you require an accommodation for anything not listed above, please explain in detail below, any reasonable accommodations you will need.
If you checked that you could do all the essential job functions listed above and answered yes to all of the questions above, please initial here:
Medical History Questionnaire
During employment have you ever had an on-the-job injury that required you to receive medical treatment away from the worksite?
If yes, please list each injury/incident below.
| Where employed at the time of injury: |
| Date of injury: |
Nature of injury (i.e., laceration, strain, etc.….)
Have you ever had any other injuries away from work that currently limit, or will limit in the future, your physical or mental ability to work?
If yes, please list each and every injury/incident below.
Nature of injury/condition:
As a result of your on-the-job or off-the-job injuries/incidents, do you require any reasonable accommodations to perform the work for which you are applying?
If yes, in accordance with the Americans with Disabilities Act as Amended please give a detailed explanation of any reasonable accommodations that you may require:
These records will be maintained in a strict compliance with HIPPA privacy rules.
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| Signature |
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Date |
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| Print Name |
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Last 4 of SSN |
