<ADD COMPANY LETTERHEAD OR LOGO>

Date of analysis: <DATE FORM COMPLETED>	Days per week: <DAYS SCHEDULED>

Employer: <COMPANY NAME>	Hours per shift: <HOURS>

Location: <WORK LOCATION>	Overtime: <YES/NO>

Job Title: <JOB TITLE>	Breaks: <YES, NO, HOW MANY>

Department: <DEPARTMENT>

General purpose of job: <JOB DESCRIPTION>

Essential functions: <MAIN DUTIES>

Marginal functions: <SUPPLEMENTAL DUTIES>

Equipment and tools used: <DESCRIPTION OF EQUIPMENT AND TOOLS>

Protective clothing and equipment used: <DESCRIPTION OF PROTECTIVE CLOTHING AND EQUIPMENT>

Special skills, education or licensure required: <SKILLS, EDUCATION OR LICENSURE REQUIRED>

Physical activity type (standing, walking, sitting, lifting, carrying, push/pull, climb, kneel, reach, grasp): <PHYSICAL ACTIVITY EXPECTED>

Physical demands (weight, time, pace): <PHYICAL DEMANDS FOR POSITION>

Environmental conditions (temperature, lighting, weather, noise, hazards, etc.): <ENVIRONMENTAL CONDITIONS>

Comments: <ANY ADDITIONAL COMMENTS>