SOP 104.23-att-2: Activity Analysis Form

Department of Corrections

SOP 104.23
Attachment 2

# Activity Analysis 10/8/19

|Use this form to conduct an analysis of a specific job - Employee is responsible for providing healthcare provider with an authorization to release medical information.|Col2|Col3|Col4|Col5|Col6|Col7|
|---|---|---|---|---|---|---|
|EMPLOYEE NAME:|WORK LOCATION:|WORK LOCATION:|WORK LOCATION:|DATE COMPLETED:|DATE COMPLETED:|DATE COMPLETED:|
|JOB TITLE:|COMPLETED BY (NAME/TITLE):|COMPLETED BY (NAME/TITLE):|COMPLETED BY (NAME/TITLE):|COMPLETED BY (NAME/TITLE):|COMPLETED BY (NAME/TITLE):|COMPLETED BY (NAME/TITLE):|
|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|I.
PURPOSE OF JOB (Describe in terms of desired outcomes, rather than in terms of how traditionally performed):

|
|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|II. JOB FUNCTIONS (Describe below each essential duty/job function in order of frequency performed; and indicate primary physical, mental and environmental demands required to perform each
function):|
|Essential Duty/Job Function Description|Essential Duty/Job Function Description|Primary Demands|Primary Demands|Primary Demands|Primary Demands|Primary Demands|
|1.|1.||||||
|2.|2.||||||
|3.|3.||||||
|4.|4.||||||
|5.|5.||||||
|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|III. REQUIRED PRODUCTIVITY (Describe or quantify output required of employee in this position, including quality of work requirements):|
||||||||
|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|IV. WORK SCHEDULE REQUIREMENTS [Describe any special qualifications required for this job, including the ability to work specific shifts (including rotating shifts)]:|
|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|V. HEALTHCARE PROVIDER COMMENTS (Check the appropriate box below and provide comments as necessary). An appointment for~~a ~~review is required if not fully released.*|
|
I release this employee to this job as described above.


















I release this employee to this job under the followingtemporary conditions/restrictions*: (DURATION:________________)OR
 permanent conditions/restrictions*:












I cannot release this employee to any part of this job at this time*. The medical rationale is as follows:






*An appointment to review the employee's condition further is scheduled for (date):






|
I release this employee to this job as described above.


















I release this employee to this job under the followingtemporary conditions/restrictions*: (DURATION:________________)OR
 permanent conditions/restrictions*:












I cannot release this employee to any part of this job at this time*. The medical rationale is as follows:






*An appointment to review the employee's condition further is scheduled for (date):






|
I release this employee to this job as described above.


















I release this employee to this job under the followingtemporary conditions/restrictions*: (DURATION:________________)OR
 permanent conditions/restrictions*:












I cannot release this employee to any part of this job at this time*. The medical rationale is as follows:






*An appointment to review the employee's condition further is scheduled for (date):






|
I release this employee to this job as described above.


















I release this employee to this job under the followingtemporary conditions/restrictions*: (DURATION:________________)OR
 permanent conditions/restrictions*:












I cannot release this employee to any part of this job at this time*. The medical rationale is as follows:






*An appointment to review the employee's condition further is scheduled for (date):






|
I release this employee to this job as described above.


















I release this employee to this job under the followingtemporary conditions/restrictions*: (DURATION:________________)OR
 permanent conditions/restrictions*:












I cannot release this employee to any part of this job at this time*. The medical rationale is as follows:






*An appointment to review the employee's condition further is scheduled for (date):






|
If released to return to work, please
indicate any prescribed medications
and their side effects which may impact
job performance (a separate sheet may
be attached):|
If released to return to work, please
indicate any prescribed medications
and their side effects which may impact
job performance (a separate sheet may
be attached):|
|Healthcare Provider Signature:|Healthcare Provider Signature:|Healthcare Provider Signature:|Date Signed:|Date Signed:|Date Signed:|Date Signed:|
|Print Name:|Print Name:|Print Name:|Telephone: ( )|Telephone: ( )|Telephone: ( )|Telephone: ( )|

Record Retention: Upon completion, this form shall be retained permanently in the employee’s local medical file.