Community Based Situational Assessment
Job Analysis definition:A job analysis is the process used to collect information about the duties, responsibilities, necessary skills, outcomes and work environment of a particular job. A job analysis can be performed by the Bureau of Rehabilitation Services Business Relations Consultants as well as a Certified Community Rehabilitation Provider. This Job Analysis Form should be used in conjunction with the employer’s job description, and also can be used in coordination with the CRP Community Based Situational Assessment Report. The Job Analysis Report provides essential information to guide the CRP concerning what information they should be collecting during the Community Based Situational Assessment. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Required Information: To be completed by Employment Specialist (ES):Report Date: FORMTEXT ?????CRP/Agency: FORMTEXT ?????Employment Specialist/Business Relations Consultant: FORMTEXT ?????Assessment Site: FORMTEXT ?????Address: FORMTEXT ?????Analysis Date(s): FORMTEXT ?????Analysis Schedule: FORMTEXT ?????Wage/Salary: FORMTEXT ?????Work Schedule: FORMTEXT ????? FORMTEXT ?????Vocational CapacityThe Vocational Capacity assessment identifies which factor or factors are required to perform a specific job/task function. Please describe in the comment section the performance required for essential job tasks. FORMTEXT ? FORMTEXT ? FORMTEXT ? Standing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Walking: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Sitting: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Driving: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Lifting: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (above waist, below waist, pounds) FORMTEXT ?????Carrying: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (pounds, distance) FORMTEXT ?????Pushing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (pounds) FORMTEXT ?????Pulling: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (pounds) FORMTEXT ?????Climbing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (ladders, stairs, scaffolds, ramps, poles) FORMTEXT ?????Balancing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Stooping: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Kneeling: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Crouching: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Reaching: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (overhead, chest level) FORMTEXT ?????Gross Motor Skills: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Fine Motor Skills: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Communication: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (oral/verbal, gestural, signing/verbal) FORMTEXT ?????Hearing Required: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (regarding coworkers, phone, public) FORMTEXT ?????Exposure to weather: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Exposure to Cold Temperatures: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Exposure to Hot Temperatures: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Exposure to Wet and/or Humid: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Noise Intensity Level: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (quiet, moderate, loud, very loud) FORMTEXT ?????Vibration: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Atmospheric Conditions: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (odor, dust, mist, gas, fumes) FORMTEXT ?????Mechanical Parts Hazard: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Toxic/Caustic Chemical Hazard: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Other Environmental Conditions: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Protective Clothing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Near Acuity: (under 20 inches) FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Far Acuity: (over 20 feet) FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Depth Perception: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Color Vision (Need to distinguish colors): FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Lighting Level: FORMCHECKBOX Dim FORMCHECKBOX Bright FORMCHECKBOX FluctuatingComments: FORMTEXT ?????Interpersonal Interaction FORMTEXT ?Describe how this position will interact with each of the following, including specific skills required: Co-workers: FORMTEXT ?????Supervisor: FORMTEXT ?????Public: FORMTEXT ?????Customers: FORMTEXT ?????Additional notes if applicable: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employment Specialist SignatureDate ................
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