ORS 4 PPD-4G ORS Collection Form Government

U.S. Department of Labor Bureau of Labor Statistics

Occupational Requirements Survey

State and local government

The BLS publishes statistical tabulations from this survey that may reveal the information reported by individual State and local governments. Upon your request, however, the BLS will hold the information provided on this survey form in confidence.	This report is authorized by law, 31 United States Code §§ 1535/FAR 17.5 of the Economy Act. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate and timely.	O.M.B. #1220-0189 Expires #/##/####
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PRINT ADDITIONAL COPIES OF PAGES 2-4, AS NEEDED.

Schedule/Quote: ___________ Work Schedule: ____________

Job Title		Work Schedule		Job Description (Y/N)	FT/PT
Job Observation (circle):		Yes - requested	Yes - offered		No
Critical Job Function:

Task List:	Minimum Education
	Experience
	Credentials
	On-the-Job Training
10% Tasks:	Driving (yes/no) duration? Vehicle Type?
	Supervisory Data:
	Lead/Supervisor/Manager/None
	Work Checked: (more than 1x/day, 1x/day, 1x/week, less than weekly)
	Supervisor Present? Y/N

Work-Related Communication:
Verbal Interactions (every few min, more than 1x/hour, more than 1x/day, once per day or less)
Speaking (duration)
People Skills (basic, more than basic)
General Public? Y/N		Crowds? Y/N			Telework? Y/N
Job Title			Work Schedule
Hearing: In-Person Spoken Voice? Y/N Telephone? Y/N Other Remote Speaking? Y/N Other Sounds? Y/N
Noise Intensity Level (quiet, moderate, loud, very loud) PPE? Y/N
Cognitive:
Control of Work Load? (machinery/equip/software, numerical perf. target, people, self-paced, other)
Work Pace? (consistent-fast, consistent-slow, varies)
Ability to step away? Y/N
Problem Solving? (more than 1x/day, 1x/day, at least 1x/week, at least 1x/month, lest than 1x/month)

Sit/Stand/Walk		Duration	Other		Notes
Sitting
Standing/Walking
Sitting/Standing at Will			Y/N
Lift/Carry (breaks at 1/10/25/50/75/100 lbs)
Most weight ever
2/3 of the time or more
1/3 up to 2/3 of the time
2% up to 1/3 of the time
Seldom (up to 2%)
Pushing/Pulling
Hands/Arms			One/Both
Feet/Legs			One/Both
Reaching/Manipulation
Overhead Reaching			One/Both
At/Below Shoulder Reaching			One/Both
Gross Manipulation			One/Both
Fine Manipulation			One/Both
Foot/Leg Controls			One/Both
Traditional Keyboarding
Postural
Work at or below knee level			Y/N/Unk
Stooping			Reqd/Choice/No/Unk
Kneeling			Reqd/Choice/No/Unk
Crouching			Reqd/Choice/No/Unk
Crawling			Reqd/Choice/No/Unk
Job Title				Work Schedule
Postural – Climbing		Duration	Other		Notes
Ramps or Stairs, Structural			Y/N
Ramps or Stairs, Work-related
Ladders, Ropes, or Scaffolds
High, Exposed Places			Y/N PPE
Vision
Near Visual Acuity			Y/N
Far Visual Acuity			Y/N
Peripheral Vision			Y/N
Environmental Conditions
Outdoors
Extreme Heat
Extreme Cold
Wetness
Humidity
Heavy Vibration
Hazardous Contaminants			Y/N PPE
Proximity to Moving Mechanical Parts			Y/N PPE

ORS Form 4 PPD-4G