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Time: R – Rarely O – Occasionally F – Frequently C – Continuously R 1 O 1-33 Exposure to electrical hazards Works in cramped quarters Exposure to dust/smoke Exposure to fumes/odors/grease/oil Works in hot/cold temperatures Travel required On call Works inside Works outside Exposure to noise Exposure to chemicals Stand on concrete Vibration Exposure to toxic materials Works at unprotected heights Shift work Walk on uneven or slippery surface Works in wet conditions Works with others Works alone Works with moving machinery Other (identify) MENTAL DEMANDS Problem solving Analytical Ability Communication – oral Communication – written Money handling Organization Interpersonal skills Calculating Concentration Perception Creativity Working with interruptions Other (list) DEXTERITY REQUIREMENTS Eye/Hand coordination Feet (foot pedals) Fingering (picking, pinching, sewing, using a calculator) Handling (holding, grasping) Wrist motion (repetitive flexion/rotation) 3 Frequency: D - Daily M - Monthly W - Weekly F 34-66 C 67-100 PIQ Task (Number/Letter) OTHER JOB FACTORS How many hours are worked per day What is the work time How many days are worked per week What days are worked Is overtime required Yes No If yes, how many hours per day Days per week or hours per week Does this position have access to confidential files and information Yes No Does the employee have to answer customer complaints Yes No What percentage of the employee’s time is spent meeting deadlines set by others How much responsibility does the employee have for the overall performance of his/her particular department 100 75 50 25 0-25 I have read this questionnaire and find it to be complete and an accurate reflection of the position..
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