GUILFORD COUNTY by HC111215203950


									                                         --------------- COUNTY
                         Questionnaire for Job Evaluation Rating System (JERS)
                                        For use in FY: 2001-2002

 Employee Name (Last, First, Initial)           Position Number           Job Code                  Salary Grade
                                                       02842                      2940                     57
 Job Title                                      Years in Position         Pay Group
 Public Health Preparedness Manager                        5                         E
 Department Name         Dept ID                Division                  Section                   Work Unit
 Public Health           PHL                 Management Svcs.             Administration    PH Preparedness
 Work Location (Location Code/Street Address)                             Work Phone Number

 Name of Immediate Supervisor                                Title of Immediate Supervisor
                                                             Asst. Health Director

Complete the following information related to the position and organizational work unit. Or, attach a current copy
of the organizational chart and write N/A in box below).

 Job Title of Immediate Supervisor                         Job Titles of Employees Reporting to Your Supervisor
 1. Asst. Health Director                                  1. Human Resources Manager
                                                           2. Budget Manager
                                                           3. Environmental Health Services Manager
                                                           4. Technology Services Manager
 Job Titles of Employees You Supervise (if any)            Number of Employees in Each Job Title
 Team Leader, PHRST-5/Public Health Regional
 Surveillance Team-5                                       (1)

NOTE: This form is to be used for the creation of a new position during a current fiscal year, as part of the annual
budget process, or as documentation of changes made to an individual position.


The JERS Questionnaire (commonly referred to as the Position Description Questionnaire or PDQ) is the primary
document used to describe and classify the essential responsibilities assigned to a position. This form is not used
to evaluate an employee's performance or judge the qualifications of an employee occupying a position, but may be
used as a basis for development of recruitment standards, interview questions, and setting performance evaluation

Supervisors completing this form must describe the primary (essential) and secondary (non-essential) duties an
employee is expected to perform. For non-supervisory positions, complete Part I only (pages 2-7); for supervisory
positions, complete the entire form. If assistance is needed, call Human Resources at 641-3324, and ask for a
classification and compensation staff member.

A.       Job Summary Statement:
         (Describe, in one or two statements, the primary purpose of this job, i.e., why the job exists).

 The primary purpose of this position is to direct, manage, and administer all phases of the Office of Public
 Health Preparedness and Response, as such serves as the --------- County Public Health Preparedness and
 Response Manager. This position is responsible for programmatic, personnel, supervisory, and fiscal decisions
 concerning this program. This position directs and coordinates the emergency preparedness and response efforts
 of 450+ public health professionals and paraprofessionals. This position leads the --------- County Department of
 Public Health and --------- County in response to public health emergencies, i.e., bioterrorism events, pandemics
 and natural and manmade disasters. This position serves as Operations Chief to the Health Director during bio-
 terrorism and public health emergency events in --------- County. This position is also responsible for
 coordination with other --------- County Emergency Response Agencies, Health Department programs, hospitals
 and with private/public providers of like services. This position is responsible for developing all operational
 procedures with respect to planning and preparing for public health emergencies and disasters, develops all
 training programs for Heath Department staff, first responders and the public with regard to preparing for public
 health emergencies, and develops and maintains media contacts and training/education for this group. The
 program employs 1 professional staff who serves the entire population of --------- County. The position reports to
 the Asst. Health Director. This position also provides managerial and administrative oversight for the Public
 Health Regional Surveillance Team-5 which is responsible for providing public health preparedness and
 response services to a 15 county region of northwest North Carolina.

B.       Essential Functions Performed:

List the job’s essential functions (usually 5 or 6 short statements) that comprise the greatest percentage of time that
an employee is accountable. DO NOT identify individual steps or tasks associated with completing the function
unless they provide a clearer understanding of the job function(s). DO NOT write a narrative description.
Essential functions may be described by cycle time (weekly, monthly, yearly, etc.), process (completing a segment
of a project), or by projects assigned and completed. Begin each statement with an action verb that identifies 1)
the outcome or result of the function, and 2) how it is achieved (the processes employed to achieve the outcome).
An example of different statements for two different jobs is as follows:

Community Social Services Aide - Ensures (action verb) citizen understanding of community improvement
programs (outcome) by explaining program goals and objectives and preparing informative brochures for
distribution (how).

Park Maintenance Aide - Maintains (action verb) cleanliness of ball fields and parking lots (outcome) by
removing leaves and other debris using rakes, shovels, and other hand tools (how).

 Essential Function(s)                                                                                      Percent of
 1. Program Management                                                                                         30%
 2. Fiscal Management                                                                                         25%
 3. Consultation and Public Relations                                                                         25%
 4. Personnel and Administrative Management                                                                   10%
 5. Professional Development                                                                                  10%

Refer to the Essential Functions previously listed to respond to the remaining questions in PART I. Responses
Last revised: 09/08/00
must be based on the normal week or work period.

A. Program Management (25%)

    1. Assess the public health needs of persons in --------- County through surveillance, investigation and review
       of health trends and goals set by the North Carolina Department of Health and Human Services and the ----
       ----- County Department of Public Health.
    2. Prepare, monitor progress, and continually update a long range strategic plan to meet the public
        health emergency response, and health risk assessment needs of --------- County, and the ---------
        County Department of Public Health.
    3. Develop Office of Public Health Preparedness and Response program content. Monitor and revise
        as indicated by changes in needs and resources.
    4. Define Office of Public Health Preparedness and Response program goals and objectives, develop
        activities to meet these goals.
    5. Lead staff to plan and monitor program activities and to develop policies and procedures for
        program implementation.
    6. Establish, supervise, and maintain the standards of practice for emergency response staff and
        emergency response programs. This work is accomplished through the Local Emergency Planning
    7. Review with Asst. Health Director the progress, activities, areas of concern, and current issues of
        the programs.
    8. Set priorities for work projects and delegate duties.
    9. Monitor and review regularly with supervisees progress toward work plan, receive updates and
        maintain an open line of communication.
    10. Assure a quality improvement plan to monitor compliance with professional and statutory
        standards of Emergency Response and Public Health Risk Assessment.
    11. Process consumer concerns to promote quality of service.
    12. Conduct quarterly review of programs for the purpose of evaluating work objectives, making
        necessary adjustments and obtaining objective feedback.
    13. Plan and implement as partners with, hospitals, Local Emergency Planning Committee and
        emergency response/public health risk assessment coalitions to implement effective, cooperative,
        public health emergency response/risk assessment initiative.
    14. Analyze data to assist in management for effectiveness and efficiency.
    15. Assure that records and materials are prepared for state review.
    16. Prepare contracts, memoranda of understandings and mutual aid agreements necessary to secure
        outside services and resources.
    17. Prepare and/or present information as needed to Board of County Commissioners and Board of

B. Fiscal Management (25%)

     1. Prepare the annual budget proposals for program budget. Base projections, expenditures, and
        revenue on historical information, trends and anticipated future program needs.
     2. Provide administrative oversight and monitoring of the budget.
     3. Prepare cost analysis and time study reports to determine efficiency and maintain control of
     4. Review monthly financial reports.
     5. Oversee statistical reporting system to assure data is reported accurately and timely.
     6. Initiate budget transfers and revisions and approve requisitions.
     7. Provide financial reports to funding sources. (Federal, State, Local contracts and grants, etc.)
Last revised: 09/08/00
     8. Explore non-county funding sources to support program endeavors.
     9. Recommend fee changes and projections of expected revenue and adjust procedures to enhance

C.    Consultation and Public Relations (20%)

      1. Work with Public Health Leaders to develop and implement program policies in keeping with
          current legislation, and regulations.
      2. Meet on an as needed basis with supervisors to plan, share information, and discuss program
      3. Coordinate with Asst. Health Director and other program managers to assure cooperation on
          cross-program activities and projects.
      4. Maintain active participation in professional organizations and with health care providers in
          related services.
      5. Consult within and outside the State and with local agencies regarding public health emergency
          response and risk assessment.
      6. Maintain close professional relationships with the NC Office of Public Health Preparedness and
          Response, NC Public Health Regional Response Team-5, US Public Health Service, Centers for
          Disease Control and Prevention, NC Health and Human Services, FBI, Environmental Protection
          Agency, NC Emergency Management, NC Department of Environment and Natural Resources,
          Local Emergency Planning Committees and local county response agencies.
      7. Serve on State and Local committees to advocate for Domestic Preparedness issues.
      8. Assure compliance with OSHA and other federal and state regulations pertaining to employee
          safety in the workplace.
      9. Meet with community groups to share information about the Emergency Response Program and
          public health emergency response/health risk assessment issues, seek support for the programs,
          and assess community needs and desires for public health emergency response/public health risk
      10. Provide information to the print and broadcast media on public health issues for emergency
          response/public health risk assessment.
      11. Upon request, inform professional and public groups on issues of public health emergency
          response/public health risk assessment.
      12. Maintain effective relationships with Agency personnel, county and state officials, and the public
          at large.
      13. Maintain strong relationship with universities and schools regarding public health emergency
          response/public health risk assessment education and research.

D.    Personnel and Administrative Management (20%)

      1. Assist in the planning for the provision of public health emergency response/public health risk
         assessment services in a future era of changing resources and change in service delivery systems,
         such as Emergency Management and Domestic Preparedness.
      2. Assist the Health Director to determine the most cost-effective manner for providing quality
         public health emergency response/public health risk assessment and implement strategies to
         achieve maximum value and reduce marginal contributions.
      3. Monitor problem situations with supervisors such as performance problems with staff members,
         morale issues, injuries on the job or illnesses affecting work performance. Provide adequate
         guidance and request consultation as indicated.
      4. Provide leadership for Administrative staff, which is comprised of representatives from the

Last revised: 09/08/00
           various disciplines for planning, coordination, implementation, and evaluation. This group
           utilizes input from consumer advisory committees, consumer satisfaction surveys, other staff
           committees, agencies, consultants, technical information and data.

E.    Professional Development (10%)

      1.   Provide leadership for staff orientation.
      2.   Provide ongoing staff education through in service presentations, regional, and state workshops.
      3.   Maintain membership in related professional organizations.
      4.   Keep current on research related to Emergency Response/Public Health Risk Assessment.
      5.   Participate in training opportunities to improve professional skills.
      6.   Provide field experiences for undergraduate and graduate students in public health emergency
           response/public health risk assessment fields.

F.    Any other duties as required/assigned.

Last revised: 09/08/00
    3. C.          Factors

Factor 1:          Knowledge

1.      List the MINIMUM knowledge and skill(s) REQUIRED to accomplish the essential functions of the job.
Also, indicate HOW the knowledge or skill is actually applied in the job duties assigned.

 Knowledge Required                                            How Applied in Performing Job Function
    1. Knowledge of Public Health principles, practices        1. Epidemiology investigations, health risk
       and programs.                                           assessments, and environmental
                                                               investigations/remediation are primary functions
                                                               of this program.
 2. Knowledge of Domestic Preparedness principles,             2. Emergency response is essential in the
 practices, and programs.                                      implementation of this program, incident
                                                               command, first responder operations, and hospital
                                                               operations are all essential functions.
 3. Knowledge of Health & Environmental Risk                   3. To protect the public’s health it is essential and
 Assessment practices, principles and programs.                necessary to conduct, environmental impact
                                                               assessments, public health investigations, and
                                                               environmental exposure assessments.
 4. Knowledge of management theory including planning          4. Planning, coordinating, training and education
 skills, personnel, administrative, budget and financial       are essential in making this program effect and
 skills                                                        without such impossible to function.
 5. Ability to communicate effectively, verbally and in        5. Communication is the basis for emergency
 writing.                                                      response, providing concise, exact and complete
                                                               information is crucial.
 6. Must be able to work well with others.                     6. This position works with people from all
                                                               stations of life, partnering and building a working
                                                                environment of cooperation is needed to
                                                               coordinate numerous agencies to come together to
                                                               respond to disasters.

 Skill Required                                                How Applied in Performing Job Function
 1. Ability to provide Incident Command functions for          1. This position will function as the Incident
 Biological Weapons of Mass Destruction events.                Commander for local and regional responses to
                                                               acts of bio-terrorism.
 2. Ability to Direct and Control mass casualty operations.    2. This position is responsible for directing mass
                                                               casualty operations during any and all disasters.
 3. Ability to direct a multi-faceted organization geared      3. This position will be responsible for leading an
 toward Public Health Emergency Response and Public            organization that provides services to the public
 Health Risk Assessment.                                       in the areas of bio-terrorism, Chemical terrorism,
                                                               radiological terrorism and naturally occurring
                                                               infectious disease incidents.
 4. Ability to Direct Disaster Management Operations for a     4. This position will be responsible for directing
 Public Health Organization.                                   an organization through disasters of all types,
                                                               from terrorism to natural disasters

 6. Ability to evaluate the capability of local and regional   6. This position is responsible for directing,
 response personnel to detect, identify, monitor, and          managing, and administering a group of
 respond to the effects of a Biological Weapon of Mass         professional emergency response staff whose job
 Destruction.                                                  is to be able to protect people from the hazards of
      7. Ability to educate, train, and increase the           Weapons of Mass Destruction.

Last revised: 09/08/00
            awareness levels of the community with regards     7. This position is responsible for raising the
            to Weapons of Mass Destruction.                    awareness level of professional, para-
        8. Ability to direct, administer, manage and control   professional, persons, citizens, agencies and
            Public Health Emergency Response to Pandemic       public/private groups in order to save lives and
            events.                                            property in a Weapons of Mass Destruction event.
        9. Ability to work cooperatively with multiple         8. This position is charged with directing the
            emergency response agencies and hospitals          response to pandemic events (disease which is
            locally.                                           endemic to a specific area on a scale not normally
        10. Ability to work with Federal and State             seen).
            Emergency Response Agencies.                       9. This position is charged with coordinating
                                                               multi agency response to Weapons of Mass
                                                               Destruction events in --------- County.
                                                               10. All response to Weapons of Mass Destruction
                                                               events will involve State and Federal Resources.

List education/degree, licenses, or certifications “REQUIRED” to perform the essential functions. Examples
include MSW, MPA, BS, EMT, Law Enforcement Officer, MD, RN, CPA, Building Inspector, etc. Identify if
required before or after employment.

       Education/Degree or                  Issuing School/ Institution            Degree/License Required
  License/Certification Required              Licensing/Certification           Prior To Hire     After Hire
 1. Bachelor of Science Degree                  Body or Authority
                                       1. Accredited College/University         1. x           1.
 2. Registered Sanitarian              2. NC Board of Sanitarian Examiners      2. x           2.
 3.                                    3.                                       3.             3.
 4.                                    4.                                       4.             4.
 5.                                    5.                                       5.             5.
 6.                                    6.                                       6.             6.

Last revised: 09/08/00
Factor 2:          Supervisory Controls

1.     Describe the source of work. This can include assignments received from a supervisor; receipt of work or
purchase orders; receipt of verbal or written complaints, citizen or visitor inquiries, referrals from other agencies,

The source of work may be generated by the immediate supervisor, citizens request for services, as a result of a
natural disaster, an act of terrorism or man-made disaster or event or referrals from other agencies.

2.      Describe instructions or guidelines that accompany regular assignments such as: are instructions detailed
and specific, or stated in general terms as to outcomes needed, or in terms of policy issues to be evaluated or

Instructions, guidelines, manuals and policies can be detailed and specific along with being stated in general terms.

3.       Who or what processes or controls determines work priorities and deadlines and how are they determined?

Work priorities are ultimately determined by this position in consultation with the Health Director and direct

4.       Who evaluates/reviews the work? Supervisor, clients, citizens, other agencies, others?

This position will evaluate and review the work of this program.

5.      How is work evaluated or reviewed (such as spot checks on previous work performed, periodic audits,
evaluating resolution of complaints, etc)?

Work is evaluated or reviewed through periodic audits and reviews with staff to insure high level delivery of

6.       How often is work checked or reviewed such as daily, weekly, monthly, etc?

Work will be reviewed on a weekly basis depending time sensitivity.

7.       Provide examples of questions or problems that are normally referred to a supervisor for resolution, either
due to lack of knowledge, or based on established procedures or policy.

When to proceed with abatement orders for imminent health hazards, when to initiate notifications procedures as a
result of a terrorist attack, when to forward problems to the county attorney’s office for further enforcement action,
how do we request assistance from the CDC, FBI, Dept of Justice or NC Emergency Management or FEMA.

Last revised: 09/08/00
Factor 3:          Guidelines

Briefly, list any laws and/or guidelines that MUST be used in this position and describe how they are applied in
normal work activities. These can be laws, rules, ordinances, reference manuals, standard operating procedures,
checklists, occupational standards, etc. Be sure to include those not committed to memory, but referenced in order
to accomplish work activities.

 Guidelines                                                     How Used or Applied

 1. Metropolitan Medical Response System Guidelines             1. Used to provide guidance on the Medical
 2. --------- County Disaster Planning Guidance                 Management of Acts of Weapons of Mass
 3. --------- County Emergency Operations Plans                 Destruction.
 4. CDC Interim Smallpox Response Plan and Guidelines           2. Used as guidance in developing response plans
 5. CDC National Pharmaceutical Stockpile Planning              to disasters in --------- County.
 Guidelines                                                     3. Used to provide guidance on how a response to
 6. --------- County Bio-terrorism Response Plan                disasters and terrorism will be handled in ---------
 7. North Carolina Bio-terrorism Response Plan                  County.
 8. CDC Interim Guidelines for Response To Anthrax              4. Used to provide a response both medically and
 9. Clean Water Act                                             operationally to a terrorist event involving
                                                                5. Guidance document on the use of the National
                                                                Pharmaceutical Stockpile for Medical
                                                                Management of casualties during Weapons of
                                                                Mass Destruction Events.
                                                                6. Guidance document on how the ---------
                                                                County Emergency Response Community handles
                                                                a Bio-terrorism/Pandemic event.
                                                                7. Guidance document on how the State of North
                                                                Carolina response plan for Bio-terrorism
                                                                interfaces with local response plans and resource
                                                                sharing and coordination.
                                                                8. Guidance document to assist in the response of
                                                                local health departments to Anthrax terrorism.
                                                                9. Used to provide guidance on Water Quality

Factor 4:          Complexity

Briefly indicate what makes the job functions difficult or complex to perform and why. Also, provide examples of
problems that are regularly resolved without the assistance of supervisors.

Partnering and coordinating local response agencies throughout --------- County poses the most difficult or complex
job function. This encompasses different ways of performing or meeting like goals in the response to acts of
terrorism. Problems that are readily solved without the assistance of supervisors might include the coordination of
communication systems where there exist differences in hardware. Compiling and receiving surveillance data.
Ensuring that all county plans can be messed into the --------- County Emergency Operations Plan, State’s response
Last revised: 09/08/00
plan and regional response plan.

Last revised: 09/08/00
Factor 5:          Scope and Effect

Describe the purpose, breadth, and depth of the position's responsibilities. What effect does routine work
performance have on other people, other organizations, and/or other processes both within and outside the
organization? "Effect" measures such things as whether the work output facilitates the work of others, provides
timely services of a personal nature, or impacts the adequacy of programs. Only the effect of properly performed
work is considered. NOTE: Functional supervision of professional or professional service contractors is covered
in this factor.

To protect the health of North Carolinians and --------- County citizens by providing, surveillance, epidemiological
and laboratory leadership, and by coordinating the public health response to a real or potential terrorist attack,
pandemic events and man made or natural disasters.

The programs help improve the quality of life for North Carolinians and --------- County citizens. Other
organizations depend on this program for emergency response, surveillance and investigative leadership to insure
the programs are viable and the staffs are available to perform their essential job functions. This program insures
the adequacy of other programs by providing guidance, leadership, partnership, coordination and resources for the
achievement of common goals.

This program also insures that work done by Environmental Consultant Companies and Environmental Clean-up
Companies is done within the scope of existing rules and regulations and that their work is of the highest quality to
prevent negative impact on public health and the environment.

Factor 6:          Public Contacts and/or Public Assistance

Describe the nature of public contacts and/or assistance with others. Identify the purpose, level, frequency,
context, and objectives of public interaction and communication with others whether they are individuals,
organizations, public officials, assistance to other employees, or citizens in order to accomplish work objectives.

This section includes essential duties required for direct personal and/or professional assistance to the public,
and/or care and custody for a client population in providing public service. This encompasses one-on-one
assistance/care giving or custody as well as similar responsibilities for groups of individuals.

Public assistance and public contacts are essential and everyday functions of this job. The very essence of the work
is to protect the publics’ health and this can only be accomplished through everyday contact where information is
gathered and exchanged. Where information is shared to enhance the knowledge base of the population to be
served. Public contact is necessary to partner and develop plans for response where multiple agencies are involved.
This everyday public contact consists of individuals, groups, organizations, communities, public officials, and

Last revised: 09/08/00
Factor 7:          Working Conditions - Environment

Describe the routine environmental conditions that characterize the normal work situation. This includes exposure
to various changes in heat/cooling, ventilation, light sources, noise, and the frequency of exposure to these
conditions. If work is primarily in an office, list "normal office environment."

 Environmental Condition(s)                                                                     Exposure Frequency
 1. Snow                                                                                        1. rare
 2. Rain                                                                                        2. often
 3. Wind                                                                                        3. often
 4. Heat                                                                                        4. often
 5. Cold                                                                                        5. often
 6. Normal Office Environment                                                                   6. often
 7. Storms                                                                                      7. rare
 8. Floods                                                                                      8. rare

Factor 8:          Working Conditions - Hazards

Identify all health and safety risks or hazards present on the job. Health and safety risks could include special
handling of materials, tools, or wearing protective clothing, exposure to hazardous chemicals, hostility, or violence,
and/or situations in which the life and health or the employee is a factor. If work is primarily in an office, list
"normal office environment."

 Hazardous Condition(s)                                                                         Exposure Frequency
 1. Exposure to Mosquitoes                                                                      1. often
 2. Exposure to Biological Agents                                                               2. rare
 3. Exposure to Chemical and Chemical Agents                                                    3. often
 4. Exposure to infectious diseases                                                             4. rare
 5. Exposure to Rodents                                                                         5. often

Factor 9:          Physical Demands

Describe the routine, as well as peak, physical demands required to perform the essential duties. This includes
physical characteristics and abilities (e.g., specific agility and dexterity requirements) and the physical exertion
involved in the work (e.g., climbing, crawling, reaching, and using quick and frequent hand/arm and foot/leg
movements). The frequency or intensity of physical exertion must also be considered (e.g., a job requiring
prolonged standing or a job requiring continued staring or listening requires greater physical effort than one that
does not require that kind of endurance.)

 Physical Demand(s)                                                                             Exposure Frequency
 1. Standing for the purposes of educating                                                      1. Often
 2. Staring and listening                                                                       2. Often
 3. Walking                                                                                     3. Often
 4.                                                                                             4.
 5.                                                                                             5.
 6.                                                                                             6.

Last revised: 09/08/00
Factor 10:         Supervision Exercised - Nature of Work Direction

Identify any responsibility for the supervision of other employees. This includes the supervisory functions of
assigning and reviewing work; establishing and enforcing work standards, coordinating work efforts, and work
planning and control. This factor only applies to positions in classifications which directly, and on a continuing
basis, supervise the work of other regularly assigned employees. A minimum of two full time equivalent
employees supervised is required to receive credit under this factor.

This position will not be directly responsible for the supervision/coordination of employees. However, will direct
and coordinate the public health emergency response efforts of 450+ public health professional and
paraprofessional staff and coordinate the response efforts of the 20,000 plus emergency response community in
response to acts of Bio-terrorism and public health emergencies in --------- County, this will include assigning,
reviewing and establishing response practices. Coordinating planning and control of response personnel
assignments and conducting after action reviews of response plans and annual performance exercises. Handling of
professional development and personal development are essential functions of this job.

Factor 11:         Supervision Exercised - Personnel Authority

Describe the degree of authority exercised over matters affecting the selection, assignment, performance appraisal,
training, promotion, reward, transfer, suspension, discipline, or removal of employees including the adjustment of
employee grievances and complaints.


Factor 12:         Supervision Exercised - Number of Subordinates

Identify all regularly scheduled personnel supervised, both directly and indirectly and whether full time or part
time employees, volunteers or similar categories of workers. Identify only those employees that are regularly
scheduled workers. Count the number of employees supervised, on under direction, in full time equivalents
(FTEs). Example: two part time employees working 20 hours per week would equal 1 FTE. Is the number of
employees supervised:

Number of Employees Supervised (FTE)

__x___Less than 5
____ More than 5 but less than 10
_____More than 10, but less than 20
_____More than 20, but less than 50
_____More than 50, but less than 100
_____More than 100, but less than 200
_____More than 200

Last revised: 09/08/00
                                             Supplemental Checklist
            Position’s Physical Activities and Requirements, Visual Acuity, and Working Conditions
                        For Compliance with The American With Disabilities Act (ADA)

 Empl      Supv          Checklist Items
                         I. The physical activity of this position (please check ALL blocks that apply)
                         Climbing - Ascending or descending ladders, stairs, scaffolding, ramps, poles and the like, using feet and legs and/or
                         hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds
                         that required for ordinary locomotion.
                         Balancing - Maintaining body equilibrium to prevent falling when walking, standing or crouching on narrow, slippery or
                         erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary
                         locomotion and maintenance of body equilibrium.
                         Stooping - Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a
 x                       considerable degree and requires full use of the lower extremities and back muscles.
                         Kneeling - Bending legs at knee to come to a rest on knee or knees.
                         Crouching - Bending the body downward and forward by bending leg and spine
                         Crawling - Moving about on hands and knees or hands and feet.
 x                       Reaching - Extending hand(s) and arm(s) in any direction.
 x                       Standing - Particularly for sustained periods of time
                         Walking - Moving about on foot to accomplish tasks, particularly for long distances or moving from one work site to
                         Pushing – Using upper extremities to press against something with steady force in order to thrust forward, downward or
                         Pulling – Using upper extremities to exert force in order to draw, drag, haul or tug objects in a sustained motion
                         Lifting – Raising objects from a lower to a higher position or moving objects horizontally from position-to-position. This
                         factor is important if it occurs to a considerable degree and requires the substantial use of the upper extremities and back
                         Fingering - Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand or arm
 x                       as in handling
                         Grasping – Applying pressure to an object with the fingers and palm
                         Feeling – Perceiving attributes of objects, such as size, shape, temperature or texture by touching with skin, particularly
                         that of fingertips
                         Talking – Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey
 x                       detailed or important spoken instructions to other workers accurately, loudly, or quickly
                         Hearing – Perceiving the nature of sounds at normal spoken word levels with or without correction. Ability to receive
                         detailed information through oral communication, and to make fine discriminations in sound, such as when making fine
 x                       adjustments on machined parts.
 x                       Repetitive motions – Substantial movements (motions) of the wrists, hands, and/or fingers
                         II. The physical requirements of this position (Please check only ONE block A through E).
                         A. Sedentary work – Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or
                         constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting
                         most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria
 x                       are met
                         B. Light work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a
                         negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces
                         greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work
                         C. Medium work - Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up
                         to 10 pounds of force constantly to move objects
                         D. Heaving work - Exerting up to 100 pounds of force occasionally, and/or up to 50 pounds of force frequently, and/or up
                         to 20 pounds of force constantly to move objects
                         E. Very heavy work – Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force
                         frequently, and/or in excess of 20 pounds of force constantly to move objects

Last revised: 09/08/00

 Empl      Supv          Checklist Items
                         III. The visual acuity requirements including color, depth perception and field of vision (Please check only ONE of the
                         blocks marked A, B, C, or D)
                         A. The worker is required to have close visual acuity to perform one or more of the following: Preparing and analyzing
                         data and figures such as accounting, transcription, sustained computer operation, extensive reading, visual inspection
                         involving small defects, small parts, operation of machines (including inspection)using measurement devices, assembly or
 x                       fabrication of parts at distances close to the eye
                         B. The worker is required to have visual acuity to perform one or more of the following: Operates machines such as lathes,
                         drill presses, power saws and mills where the seeing job is at or within arm’s reach; performs mechanical or skilled trades
                         tasks of a non-repetitive nature such as carpenters, technicians, service people, plumbers, painters, mechanics, etc
                         C. The worker is required to have visual acuity to be the operator of trucks, forklifts, cranes and other equipment
                         D. The worker is required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work
                         assigned (i.e. custodial, food services, general laborer, etc.)
                         IV. The conditions of the worker will be subject to in this position (Please check All that apply). The worker is subject
 x                       Inside environmental conditions – Protection from weather conditions but not necessarily from temperature changes
                         Outside environmental conditions - No effective protection from weather.
 x                       Both environmental conditions – Activities occur inside and outside.
 x                       Extreme cold - Temperatures below 32 degrees for periods of more than one hour.
                         Extreme heat - Temperatures above 100 degrees for periods of more than one hours.
 x                       Noise – There is sufficient noise to cause the worker to shout in order to be heard above the ambient noise level.
                         Vibration – Exposure to oscillating movements of the extremities or whole body.
                         Hazards – Includes a variety of physical conditions, such as proximity to moving mechanical parts, electrical current,
 x                       working on scaffolding and high places, exposure to high heat or exposure to chemicals.
                         Atmospheric conditions - One or more of the following conditions that affect the respiratory system of the skin – Fumes,
 x                       odors, dusts, mists, gases or poor ventilation.
 x                       Oils – There is air and/or skin exposure to oils and other cutting fluids.
                         Wear respiration devices.
                         Work in frequently in close quarters, crawl space, shafts, manholes, small enclosed rooms, small sewage and water line
                         pipes, and other areas that could cause claustrophobia.
                         Function in narrow aisles or passageways.
                         None – The worker is not substantially exposed to adverse environmental conditions (such as in typical office or
                         administrative work

 Employee’s Signature                                                                           Date

 Supervisor’s Signature                                                                         Date

 Department Or Division Director’s Signature                                                    Date

ADA-Rev: 09/08/00

Last revised: 09/08/00

 Date Reviewed
 Notes for File

Last revised: 09/08/00

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