DFEC evaluation
General lower extremity
Hip
Knee
Other
Ankle
Toe(s)
Instructions:
Please complete one form for each body part
Strength factors:
A. STAND and/or walk (with normal breaks) for a total of:
Less than 2 hours in an 8-hour workday
At least 2 hours in an 8-hour workday
About 6 hours in an 8-hour workday
Medically required hand-held assistive device is necessary for ambulation
B. SIT (with normal breaks) for a total of
Less than about 6 hours in an 8-hour workday
About 6 hours in an 8-hour workday
Must periodically alternate sitting and standing to relieve pain or discomfort
Not at all
Less than 10 pounds
10 pounds
11-20 pounds
21-25 pounds
26-50 pounds
1.
Less than 10 pounds
10 pounds
11-20 pounds
21-25 pounds
26-50 pounds
LIFT/CARRY
Occasionally
Frequently
up to 1/3rd day
1/3rd to 2/3rd day
Less than 10 pounds
Less than 10 pounds
10 pounds
10 pounds
11-20 pounds
11-20 pounds
21-25 pounds
21-25 pounds
26-50 pounds
26-50 pounds
Continuously
2/3rd day or more
Less than 10 pounds
10 pounds
11-20 pounds
21-25 pounds
26-50 pounds
PUSH/PULL
Less than 10 pounds
Less than 10 pounds
10 pounds
10 pounds
11-20 pounds
11-20 pounds
21-25 pounds
21-25 pounds
26-50 pounds
26-50 pounds
Less than 10 pounds
10 pounds
11-20 pounds
21-25 pounds
26-50 pounds
Physical (Non-exertional force)
Not at all
Occasionally
(up to 1/3rd day)
Climb
Balance
Stoop
Kneel
Crouch
Crawl
Reach
Handle
Finger
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Frequently
(1/3rd to 2/3rd day)
Continuously
(2/3rd day or more)
DFEC evaluation
Environmental Factors Include:
Not at all
Occasionally
(up to 1/3rd day)
Frequently
(1/3rd to 2/3rd day)
Exposure to Weather
Extreme Cold
Extreme Heat
Wet and/or Humid
Vibration
Atmospheric Conditions
Proximity to Moving Mechanical
Parts
Exposure to Electrical Shock
Work in High Exposed Places
Exposure to Radiation
Working with Explosives
Exposure to Toxic or Caustic
Chemicals
Other Environmental Conditions
Signature
Date
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Continuously
(2/3rd day or more)