Get Function Evaluation Form 2013-2024

Job Function Evaluation Form When returning employees back to work in a modified position it s important to conduct a job function evaluation for the new position. The purpose of a job function evaluation is to gather data on critical job factors that can be shared with the medical provider and CNA. The analysis starts with a summary of the whole job process that is broken down into smaller steps. Use the Job Function Evaluation Guide to help you complete this form for each position* Date Employee Name / Employee Job Title Company Department 1. Job Functions provide a basic description of the job duties 2. Work Location Stressors Indoors Chemicals Required Protective Equipment Outdoors Heat Inhalation Respirator Coveralls Below ground Cold Skin contact Fall harness Gloves Elevated areas Loud noise Safety boots Hard hat Describe 3. Work Postures Work is performed in which posture Indicate percentage of their job. Constant Posture Frequent Occasional 67 - 100 34 - 66 1 - 33 Not Applicable Standing Sitting Walking Climbing Kneeling Reach Push Pull Kneel Over 4. Physical Demands Lifting Describe Materials Weight of Materials Position of Lift lbs. Floor to waist Frequency of Lifting Waist to shoulder Above shoulder Carrying Tool Usage Describe or list tools Frequency of Usage forceful grip required feet Distance Carried Work Hours Yes No Total Minutes Provided for Breaks or Rest Periods 5. Miscellaneous Indicate any other special or unusual job demands For more information visit www. cna*com/returntowork. CNA is a registered trademark of CNA Financial Corporation* Copyright 2013 CNA. All rights reserved* RTW INST JFEF 050313 minutes. The analysis starts with a summary of the whole job process that is broken down into smaller steps. Use the Job Function Evaluation Guide to help you complete this form for each position* Date Employee Name / Employee Job Title Company Department 1. Use the Job Function Evaluation Guide to help you complete this form for each position* Date Employee Name / Employee Job Title Company Department 1. Job Functions provide a basic description of the job duties 2. Work Location Stressors Indoors Chemicals Required Protective Equipment Outdoors Heat Inhalation Respirator Coveralls Below ground Cold Skin contact Fall harness Gloves Elevated areas Loud noise Safety boots Hard hat Describe 3. Job Functions provide a basic description of the job duties 2. Work Location Stressors Indoors Chemicals Required Protective Equipment Outdoors Heat Inhalation Respirator Coveralls Below ground Cold Skin contact Fall harness Gloves Elevated areas Loud noise Safety boots Hard hat Describe 3. Work Postures Work is performed in which posture Indicate percentage of their job. Constant Posture Frequent Occasional 67 - 100 34 - 66 1 - 33 Not Applicable Standing Sitting Walking Climbing Kneeling Reach Push Pull Kneel Over 4. Work Postures Work is performed in which posture Indicate percentage of their job. Constant Posture Frequent Occasional 67 - 100 34 - 66 1 - 33 Not Applicable Standing Sitting Walking Climbing Kneeling Reach Push Pull Kneel Over 4. Physical Demands Lifting Describe Materials Weight of Materials Position of Lift lbs. Floor to waist Frequency of Lifting Waist to shoulder Above shoulder Carrying Tool Usage Describe or list tools Frequency of Usage forceful grip required feet Distance Carried Work Hours Yes No Total Minutes Provided for Breaks or Rest Periods 5. .