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Americans with Disabilities Act <br />Supplemental Information Form <br />In order to assist in developing class descriptions which recognis requested <br />to complete the attached ADA supplemental information form. Plensory <br />requirements that are absolutely necessary to perform the essential functions of your job and those environ <br />If options provided are not applicable, please do not check the <br /> <br />The employee should check the appropriate box on the left side othe employee <br />and verify the requirements of the position by checking the appr <br /> <br />1.The physical requirements of this position. <br /> <br />Does this job require that weight be lifted or force be exerted?elow. <br /> Employee Amount of Time SupervisorÓs Input <br /> None up to 1/3 1/3to2/3 2/3 & up None up to 1/3 1/3to2/3 2/3 & up <br /> <br />Up to 10 pounds of force <br />Up to 25 pounds of force <br /> <br />Up to 50 pounds of force <br /> <br />Up to 100 pounds of force <br />In excess of 100 pounds of force <br />What is being lifted: <br /> <br />2.The physical activity of this position. <br /> <br />How much on-the-job time is spent in the following physical actixes below. <br /> Employee Amount of Time SupervisorÓs Input <br /> None up to 1/3 1/3to2/3 2/3 & up None up to 1/3 1/3to2/3 2/3 & up <br /> <br />Stand <br />Walk <br />Sit <br />Speak or hear <br /> <br />Use hands to finger, handle or feel <br />Climb or balance <br />Stoop, kneel, crouch or crawl <br />Reach with hands and arms <br />Taste or smell <br /> <br />Push or pull <br />Lifting <br />Repetitive Motions <br /> <br />Employee (check all that apply) Supervisor (verify job requirement) <br />3.The sensory requirements of the position are: <br /> <br /> Visual Acuity <br /> Standard vision requirements .................................................................................................. <br /> Close vision .................................................................................................................. <br /> Distance vision ........................................................................................................................ <br /> Ability to adjust focus ....................................................................................................... <br /> Depth perception .............................................................................................................. <br /> Color perception ............................................................................................................. <br /> Night vision .................................................................................................................. <br /> Peripheral vision ............................................................................................................. <br /> Page 6 <br />