Resp. Co: / HID: / Name: / Status: / EJTA ID: /
Construction Mngr: Manager Name: /
Prime Contractor:
/ MSAOrg Code: / Level 2 Subcontractor:
Track Code: / Level 3 Subcontractor:
Project code: / Primary Area:
Job Title: / Other Area Info:
COCS: / Shift:
Occupation / Other Shift Info:
Admin. Employer:
Other Admin. Employer:
Signatures
Name: / Date:Manager:
Industrial Hygienist:
Employee:
Creation Date:
Send To Medical Date:
Effective Date:
Essential Functions
1: List at least three functions to be performed that describe type of work employee performs2:
3:
4:
5:
6:
7:
8:
Comments:
Include Project Number and release number
Resp. Co: / HID: / Name: / Status: / EJTAID: /
Physical Job Demands
0:Never 1:Rarely 2:Occasionally, Up to 1/3 of the Time 3:Frequently >1/3 of the Time Q:Job RequirementYes/No / 0 / 1 / 2 / 3 / Q
1 / Sitting / 0 / 1 / 2 / 3 / Q
2 / Standing / 0 / 1 / 2 / 3 / Q
3 / Walking (Even Surfaces) / 0 / 1 / 2 / 3 / Q
4 / Walking (Uneven Surfaces) / 0 / 1 / 2 / 3 / Q
5 / Running / 0 / 1 / 2 / 3 / Q
6 / Crawling / 0 / 1 / 2 / 3 / Q
7 / Climbing Legs Only / 0 / 1 / 2 / 3 / Q
8 / Climbing (Hands and Legs) / 0 / 1 / 2 / 3 / Q
9 / Twisting / 0 / 1 / 2 / 3 / Q
10 / Straight Pulling / 0 / 1 / 2 / 3 / Q
11 / Pulling Hand Over Hand / 0 / 1 / 2 / 3 / Q
12 / Pushing / 0 / 1 / 2 / 3 / Q
13 / Fine Finger Movement (Not Keyboarding/Mousing) / 0 / 1 / 2 / 3 / Q
14 / Uses Both Hands / 0 / 1 / 2 / 3 / Q
15 / Uses Both Legs / 0 / 1 / 2 / 3 / Q
16 / Operating Motor Vehicles / 0 / 1 / 2 / 3 / Q
17 / Operating Heavy Equipment / 0 / 1 / 2 / 3 / Q
18 / Operating Machinery / 0 / 1 / 2 / 3 / Q
19 / Material Handling Equipment / 0 / 1 / 2 / 3 / Q
20 / Confined Areas / 0 / 1 / 2 / 3 / Q
21 / Work in Hot Environments / 0 / 1 / 2 / 3 / Q
22 / Work in Cold Environments / 0 / 1 / 2 / 3 / Q
23 / Use of Foot Pedal/Foot Controls / 0 / 1 / 2 / 3 / Q
24 / Above Shoulders Work / 0 / 1 / 2 / 3 / Q
25 / Instrument Scan/Survey / Yes / No
25a / Instrument Walking Stick / 0 / 1 / 2 / 3 / Q
25b / Instrument Equipment <5 lbs / 0 / 1 / 2 / 3 / Q
25c / Instrument Equipment 5 – 10 lbs / 0 / 1 / 2 / 3 / Q
25d / Instrument Equipment >10 – 20 lbs / 0 / 1 / 2 / 3 / Q
25e / Instrument Equipment >20 lbs / 0 / 1 / 2 / 3 / Q
26 / Lifting >10 lbs / Yes / No
26a / Lifting >75 lbs / 0 / 1 / 2 / 3 / Q
26b / Lifting >55 £75 lbs / 0 / 1 / 2 / 3 / Q
26c / Lifting >25 £55 lbs / 0 / 1 / 2 / 3 / Q
26d / Lifting >10 £25 lbs / 0 / 1 / 2 / 3 / Q
27 / Carrying >10 lb / Yes / No
27a / Carrying >75 lb / 0 / 1 / 2 / 3 / Q
27b / Carrying >55 £75 lb / 0 / 1 / 2 / 3 / Q
27c / Carrying >25 £55 lb / 0 / 1 / 2 / 3 / Q
27d / Carrying >10 £25 lb / 0 / 1 / 2 / 3 / Q
27e / Single Hand Carrying / 0 / 1 / 2 / 3 / Q
Resp. Co: / HID: / Name: / Status: / EJTAID: /
0:Never 1:Rarely 2:Occasionally, Up to 1/3 of the Time 3:Frequently >1/3 of the Time Q:Job Requirement
28 / Highly Repetitive Activities / Yes / No
28a / Intense Keying/Mousing >4hr/Shift / Yes / No
28b / Other Activities >2 hr/Shift / Yes / No
29 / Kneeling / Yes / No
29a / Greater Than 2 hr/Shift / Yes / No
30 / Crouching/Squatting / Yes / No
30a / >2hr/Shift / Yes / No
31 / Bending Neck or Back >30 degrees / Yes / No
31a / W/O Support or Varying Posture >2 hr/Shift / Yes / No
32 / Hand Grip ³10-lb Force or
Objects >2hr/Shift / Yes / No
33 / Finger Pinch ³4-lb Force or
³2lb Object / Yes / No
33a / >2 hr/Shift / Yes / No
34 / Hand/Arm Vibration / Yes / No
34a / High >30min/Shift
(i.e., Jack Hammer) / Yes / No
34b / Moderate >2 hr/Shift
(i.e., Sander) / Yes / No
35 / Repeated Impact W/Hand/Knee as Hammer / Yes / No
35a / >2 hr/Shift / Yes / No
Resp. Co: / HID: / Name: / Status: / EJTAID: /
Medical Qualifications
1 / Crane Operator / Yes / No
2 / DOT Medical needed for CDL license or CMV driver / Yes / No
3 / Fissile Material Handler / Yes / No
4 / Respirator Wearer / Yes / No
5 / Human Reliability Program / Yes / No
6 / Quality Control Inspector / Yes / No
6a / AWS Vision Test / Yes / No
7 / Nuclear Reactor Operator / Yes / No
8 / Tower Climber / Yes / No
9 / Hanford Patrol / Yes / No
9a / Security Officer / Yes / No
9b / Hanford Patrol Security Police Officer I / Yes / No
9c / Hanford Patrol Security Police Officer II / Yes / No
9d / Hanford Patrol Security Police Officer III / Yes / No
10 / Firefighter / Yes / No
10a / HAZMAT / Yes / No
11 / Underwater Diver (Select one type below) / Yes / No
11a / Scientific Diver (NOAA) / Yes / No
11b / Commercial Diver / Yes / No
12 / OCRWM Testing Activities Per TN 8-027 (K Basins) / Yes / No
13 / High Magnetic Field Operator/Support – (PNNL only) / Yes / No
14 / Bio-Safety Lab Worker – Human Pathogen (PNNL only) / Yes / No
15 / Engineered Nanoparticle Worker (PNNL Only) / Yes / No
16 / Security Officer (PNNL Only) / Yes / No
Resp. Co: / HID: / Name: / Status: / EJTAID: /
Potential Exposure Hazards
0: Does Not Work With or Around1a: Potential, Works Around
1b : <10% of Criteria
1c: 10% of Criteria to <Criteria / 2: ≥Criteria for <30 Days/Year
3: Criteria for ≥30 Days/Year
Qd: Quantitative Data Available
Hz: Hazardous Waste Related
Yes/No
/ 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz1 / Arsenic Inorganic / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
2 / Asbestos / 0 / 1a / 1b / 1c / 2 / 3 /
Qd / Hz
2a / Year of First Exposure / 0
3 / Benzene / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
4 / Beryllium / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
5 / Cadmium Inorganic / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
6 / Formaldehyde / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
7 / Chromium (Hexavalent) / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
8 / Lead Inorganic / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
9 / Noise / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
10 / Laser Light / 0 / 1a / 1b / 1c / 2 / 3 / Hz
11 / Paint/Resins / Yes / No
11a / Lead / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
11b / Solvents / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
12 / Welding / Yes / No
12a / Nickel (SS) / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
12b / Other Welding / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
13 / Carcinogens
(if not checked elsewhere) / Yes / No
13a / A1 or OSHA / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
13b / Other Carcinogens / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
14 / Particulates / Yes / No
14a / Coal Dust / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
14b / Synthetic Vitreous Fibers / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
14c / Other Particulates / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
* Use the list at end of document and insert any solvents, welding metals, carcinogens, or particulates that employee may be exposed to and the level at which they may be exposed (0,1a, 1b, 1c, 2, 3)
*
16 / Other Solvents / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
17 / Other Corrosives / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
18 / Isocyanates / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
19 / Epichlorohydrin / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
20 / Chlorine / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
21 / PCBs / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
22 / Ammonia / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
23 / Mercury / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
24 / Other Chemicals / 0 / 1a / 1b / 1c / 2 / 3 / Qd / Hz
*
* Use the list at end of document and insert any solvents, corrosives, or other chemicals that employees may be exposed to and the level at which they may be exposed (0,1a, 1b, 1c, 2, 3)
Other Exposure Information
1 / Radiation Worker II / Yes / No2 / High Vibration / Yes / No
3 / Licensed Pesticide Applicator / Yes / No
4 / Greenhouse Work: WBGT ³80F / Yes / No
5 / Impermeable Clothing / Yes / No
6 / Physically Stressful Environments / Yes / No
7 / Bloodborne Pathogens / Yes / No
7a / Communicable Disease (e.g. Health Care Worker) / Yes / No
8 / Routinely work within a RCRA/CERCLA boundary / Yes / No
9 / Work within a Tank Farm RCRA/CERCLA boundary / Yes / No
10 / Laboratory Animals / Yes / No
10a / Laboratory Animal Handler / Yes / No
10b / Primate Worker – General / Yes / No
10c / Cold Blooded Animal / Yes / No
11 / Wildlife/Wild Animals / Yes / No
11a / Wild Mammal Handler / Yes / No
11b / Fowl/Avian Worker / Yes / No
12 / Member of HAZMAT emerg. Response Org? / Yes / No
12a / Designated responder into EVENT scene: / Yes / No
13 / Beryllium Assigned Worker / Yes / No
14 / Operate/Potential Exposure-Class IIIB or IV L/LSystem / Yes / No
15 / Asbestos Class I, II, or III Construction Worker / Yes / No
15a / Year of First Exposure
0
16 / Tank Farm Entry Required / Yes / No
17 / ATL ONLY – 29 CFR 1910.1450 for Beryllium / Yes / No
17a / BE Medical Monitoring / Yes / No
11/1/2012
Common Occupational Classification System (COCS) CodesLower Level Code / Description
General Managers, Executives, First line Supervisors Program/Project managers
M010 / First Line Supervisors
M020 / General Managers and Executives
M030 / Project and Program Managers
M040 / Other Managers
Engineers
E010 / Chemical Engineers
E020 / Civil Engineers
E030 / Computer Engineers
E040 / Electrical Engineers
E050 / Environmental Engineers
E060 / Industrial Engineers
E070 / Mechanical Engineers
E080 / Nuclear Engineers
E090 / Petroleum / Mining Engineers
E100 / Plant Engineers
E110 / Quality Control Engineers
E120 / Safety Engineers
E130 / Other Engineers
Scientists
S010 / Chemist
S020 / Environmental Scientist
S030 / Geologist
S040 / Life Scientists
S050 / Materials Scientists
S060 / Mathematician
S070 / Physicist
S080 / Social Scientists
S090 / Other Scientists
Administrative and Other Professional Occupations
P010 / Accountants and Auditors
P020 / Architects
P030 / Buyers, Procurement and Contracting Specialists
P040 / Communication Specialists
P050 / Compliance Inspectors
P060 / Computer Systems Analysts
P070 / Costs Estimators and Planners and Schedulers
P080 / Health Physicists
P090 / Industrial Hygienists
P100 / Lawyers
P110 / Personnel and Labor Relations Specialists
P120 / Physicians
P130 / Physician Assistants, Nurses and Other Medical Support Occupations
P140 / Safeguards and Other Security Specialists
P150 / Trainers
P160 / Technical Writers and Editors
P170 / Other Administrative and Professional Other Occupations
General Administrative, Secretarial and Clerical Support Staff
G010 / Administrative Assistants
G020 / Office Clerks (General)
G030 / Office Clerks (Specialized)
G040 / Secretaries
G050 / Typists and Word Processors
G060 / Other General Administrative, Secretarial and Clerical Support Staff
Technicians
T010 / Computer Operators/Coders
T020 / Drafters
T030 / Engineering Technicians
T040 / Environmental Sciences Technicians
T050 / Health Physics Technicians
T060 / Industrial Safety and Health Technicians
T070 / Instrument and Control Technicians
T080 / Laboratory Technicians
T090 / Media Technicians
T100 / Survey and Mapping Technicians
T110 / Other Technicians
Crafts
C010 / Carpenters
C020 / Electricians
C030 / Heating Air-Conditioning and Refrigeration Mechanics (HVAC)
C040 / Machinists
C050 / Masons
C060 / Millwrights
C070 / Painters
C080 / Plumbers and Pipefitters
C090 / Structural and Metal Workers
C100 / Vehicle and Mobile Equipment Mechanics
C110 / Welders
C120 / Other Crafts
Operators
R010 / Chemical System Operators
R020 / Drillers
R030 / Material Moving Equipment Operators
R040 / Nuclear Plant Operators
R050 / Nuclear Waste Process Operators
R060 / Production Systems Operators
R070 / Utilities Systems Operators
R080 / Other Operators
Laborers and General Service Workers
L010 / Firefighters
L020 / Food Service Workers
L030 / Janitors and Cleaners
L040 / Laundry Workers
L050 / Material Handlers, Helpers and Laborers (General)
L060 / Material Handlers, Helpers and Laborers (Specialized)
L070 / Light Vehicle Drivers
L080 / Security Guards
L090 / Other Laborers and General Services Workers
11/1/2012
A1 or OSHA Carcinogens
2-Acetylaminofluorene / Chromite Ore Processing (Chromate)3,3'-Dichlorobenzidine (and its salts) / Coal Tar Pitch Volatiles as Benzene Solubles
4-Aminodiphenyl / Ethyleneimine
4-Dimethylaminoazo-Benezene / Insoluble Cr VI Compounds, NOC
4-Nitrobiphenyl / Methyl Chloromethyl Ether
Alpha-Napthylamine / Nickel Sulfide Roasting, Fume and Dust
Benzidine / N-Nitrosodimethylamine
Beta-Naphthylamine / Vinyl Chloride
Beta-Propiolactone / Water Soluble CrVI Compounds, NOC
Bis-Chloromethyl Ether / Zinc Chromates
Other Carcinogens
Regulated Carcinogens: / Lindane and Other Hexachlorocyclohexane Isomers2-Nitropropane / Melphalan
3,3-Dimethoxybenzidine & 3,3-Dimethoxybenzidine 2HCl / Methoxsalen with Ultraviolet A Therapy (Puva)
3,3-Dimethylbenzidine / Methyl Iodide
3-Chloro-2-Methylpropene / Methylene chloride
4-(N-Nitrosomethyl-Amino)-I-(3-Pyridyl)-L-Butanone(NNK) / Michler's Ketone