Common use of FUNCTIONAL ABILITIES Clause in Contracts

FUNCTIONAL ABILITIES. Walking (continuously): □ up to 20 min; □ up to 1 hour; □ no restriction; □ Other (e.g., uneven ground) Standing (continuously): □ up to 20 min; □ up to 1 hour; □ no restriction; □ Other Sitting (continuously): □ up to 30 min; □ up to 1 hour; □ no restriction; □ Other Stair climbing: □ unable □ 2 – 3 steps only; □ own pace □ assisted □ no restriction Lifting floor to waist: □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Lifting waist to shoulder: □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Carrying □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Reaching (please specify) □ no restriction; □ Other Bending – repetitive (please specify) □ no restriction; □ Other Limited ability to used left hand to: □ hold objects; □ grip; □ type; □ write Limited ability to used right hand to: □ hold objects; □ grip; □ type; □ write Completely unable to use left hand to: □ hold objects; □ grip; □ type; □ write Completely unable to use right hand to: □ hold objects; □ grip; □ type; □ write Hours per day: □ 4 hours □ 6 hours □ 8 hours COGNITIVE ABILITIES: □ no restriction □ less then 4 hours (specify) Twisting – repetitive (please specify) □ no restriction; □ Other Employee is: □ Left handed □ Right handed □ Ambidextrous Concentration □ limited capacity □unable to perform □ no restriction; □ Other Attention □ limited capacity □unable to perform □ no restriction; □ Other Memory □ limited capacity □unable to perform □ no restriction; □ Other Organization/Planning □ limited capacity □unable to perform □ no restriction; □ Other Deadline Pressures □ limited capacity □unable to perform □ no restriction; □ Other Time Management □ limited capacity □unable to perform □ no restriction; □ Other Attention to Detail □ limited capacity □unable to perform □ no restriction; □ Other Multi-tasking □ limited capacity □unable to perform □ no restriction; □ Other Responsibility/Accountability□ limited capacity □unable to perform □ no restriction; □ Other Problem Solving □ limited capacity □unable to perform □ no restriction; □ Other Exposure to Confrontation □ limited capacity □unable to perform □ no restriction; □ Other Interpersonal Contact □ limited capacity □unable to perform □ no restriction; □ Other Exposure to heat/cold □ limited capacity □unable to perform □ no restriction; □ Other Exposure to dust/fumes/odour □ limited capacity □unable to perform □ no restriction; □ Other Exposure to chemicals □ limited capacity □unable to perform □ no restriction; □ Other □ Other (please specify)

FUNCTIONAL ABILITIES. Walking (continuously): □ up to 20 min; □ up to 1 hour; □ no restriction; □ Other (e.g., e.g. uneven ground) Standing (continuously): □ up to 20 min; □ up to 1 hour; □ no restriction; □ Other Sitting (continuously): □ up to 30 min; □ up to 1 hour; □ no restriction; □ Other Stair climbing: □ unable una ble □ 2 – 3 steps only; □ own pace □ assisted □ no restriction Lifting floor to waist: □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other other Lifting waist to shoulder: □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other other Carrying □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Reaching (please specify) □ no restriction; □ Other Bending – repetitive (please specify) □ no restriction; □ Other Twisting – repetitive (please specify) □ no restriction; □ Other Employee is: □ Left handed □ Right handed □ Ambidextrous Limited ability to used left hand to: □ hold objects; □ grip; □ type; □ write Limited ability to used right hand to: □ hold objects; □ grip; □ type; □ write Completely unable to use left hand to: □ hold objects; □ grip; □ type; □ write Completely unable to use right hand to: □ hold objects; □ grip; □ type; □ write Hours per day: □ 4 hours hours□ 6 hours hours□ 8 hours COGNITIVE ABILITIES: hours□ no restriction □ less then 4 hours (specify) Twisting – repetitive (please specify) □ no restriction; □ Other Employee is: □ Left handed □ Right handed □ Ambidextrous Concentration □ limited capacity □unable to perform □ no restriction; □ Other Attention □ limited capacity □unable to perform □ no restriction; □ Other Memory □ limited capacity □unable to perform □ no restriction; □ Other Organization/Planning □ limited capacity □unable to perform □ no restriction; □ Other Deadline Pressures □ limited capacity □unable to perform □ no restriction; □ Other Time Management □ limited capacity □unable to perform □ no restriction; □ Other Attention to Detail □ limited capacity □unable to perform □ no restriction; □ Other Multi-tasking □ limited capacity □unable to perform □ no restriction; □ Other Responsibility/Accountability□ limited capacity □unable to perform □ no restriction; □ Other Problem Solving □ limited capacity □unable to perform □ no restriction; □ Other Exposure to Confrontation □ limited capacity □unable to perform □ no restriction; □ Other Interpersonal Contact □ limited capacity □unable to perform □ no restriction; □ Other Exposure to heat/cold □ limited capacity □unable to perform □ no restriction; □ Other Exposure to dust/fumes/odour □ limited capacity □unable to perform □ no restriction; □ Other Exposure to chemicals □ limited capacity □unable to perform □ no restriction; □ Other □ Other (please specify)