Date_____________________     Analyst________________________

Department___________________________________________________

Job__________________________________________________________

Task_________________________________________________________

Efforts per Minute____________________

Percent Duration of Effort____________

Hours per Day at this task____________

Intensity of Effort (circle one): 

 Light     Somewhat Hard     Hard     Very Hard     Near Maximal

Hand/Wrist Postures (circle one):

Very Good     Good     Fair     Bad     Very Bad

Speed of Work (circle one):

Very Slow     Slow     Fair     Fast     Very Fast



Strain Index (from program):__________________





________________________________     __________________

Signature of Analyst				Date