SOP_NUMBER: 104.23-att-2
TITLE: Activity Analysis Form
REFERENCE_CODE: IVO04-0003
DIVISION: Administrative & Finance
TOPIC_AREA: 104 Policy-HR Programs/Support/Assistance
EFFECTIVE_DATE: 2019-10-08
WORD_COUNT: 1274
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/556820
URL: https://gps.press/sop-data/104.23-att-2/
SUMMARY:
This is a standardized form used to conduct a comprehensive analysis of a specific job position within the Georgia Department of Corrections. The form documents job purpose, essential duties and functions, productivity requirements, and work schedule demands. It requires a healthcare provider to review the job demands and determine whether an employee can be released to perform the job without restrictions, with temporary or permanent restrictions, or cannot be released at all. The employee must provide authorization for the healthcare provider to release medical information.
KEY_TOPICS: activity analysis, job analysis, job duties, essential functions, physical demands, mental demands, work capacity evaluation, fitness for duty, job description, healthcare provider clearance, work restrictions, temporary restrictions, permanent restrictions, job functions, work schedule, productivity requirements
ATTACHMENTS:
1. WC-240a Job Analysis Form
URL: https://gps.press/sop-data/104.23-att-1/
2. Activity Analysis Form
URL: https://gps.press/sop-data/104.23-att-2/
3. Transitional Employment Plan
URL: https://gps.press/sop-data/104.23-att-3/
4. Transitional Employment Tracking Form
URL: https://gps.press/sop-data/104.23-att-4/
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FULL TEXT:
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## **Department of Corrections**
# Activity Analysis
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 followingtemporary 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 followingtemporary 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 followingtemporary 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 followingtemporary 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 followingtemporary 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.