Current Progress
7/7

The following physical demands analysis of the member’s occupation is to be completed by his/her supervisor. In the appropriate column, please specify the frequency for which the following activities are regularly performed:

  • Infrequent = 0-33% of the workday
  • Frequent = 34-66% of the workday
  • Constant = 67-100% of the workday

PHYSICAL ACTIVITIES

Activity
Walking
Sitting
Standing
Driving/Operating Machinery
Climbing up and down the stairs
Does the employee's occupation require repetitive movement?

Lifting
0-10 lb.
11-20 lb.
21-50 lb.
51-100 lb.
100+ lb.
Does the plan member use a lifting device?

Pushing / Pulling
0-10 lb.
11-20 lb.
21-50 lb.
51-100 lb.
100+ lb.

COGNITIVE ACTIVITIES

Activity
Understanding and memory (Understanding and remembering instructions)
Sustained concentration (Maintaining attention and concentration for extended periods)
Social interaction (Interaction with co-workers and/or the general public)
Adaptation and multitasking (Response to frequent changes, juggle tasks and prioritizes)
Meeting deadlines (The work involves time pressure and deadlines)
Responsibility and accountability
(Errors in judgement or attention can have significant consequences)

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I certify that the information in this form is true and complete, to the best of my knowledge.

Please note : The information in this statement will be kept in a group life, health or disability benefits file with Manulife and might be accessible by the plan member or third parties to whom access has been granted or those authorized by law. By providing the information you consent to such unedited release of any information contained herein.
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