WORK HISTORY REPORT

Provide more information about Job No. 1 listed in Section 2. Estimate hours and pay, if needed.

JOB TITLE NO. 1*

Rate of Pay:*

Per (Check One):*

Hours per Day:*

Days per Week:*

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday. *

0/540

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.*

0/425

If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. *

0/425

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for. *

0/425

Did this job require you to interact with coworkers, the general public, or anyone else?*

YesNo

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek.*

0/525

Tell us how much time you spent doing the following physical activities in a typical workday. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day. The example below shows an 8-hour workday with 2 hours standing and walking, and 6 hours sitting (8 hours total).

Activities

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Activities

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle):

Activities

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday.*

0/275

Select the heaviest weight lifted:*

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):*

Did this job expose you to any of the following? Check all that apply.*

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.*

0/275

Explain how your medical conditions would affect your ability to do this job.*

0/275

Provide more information about Job No. 2 listed in Section 2. Estimate hours and pay, if needed.

JOB TITLE NO. 2*

Rate of Pay:*

Per (Check One):*

Hours per Day:*

Days per Week:*

For the job you listed in Job Title No. 2, describe in detail the tasks you did in a typical workday. *

0/540

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.*

0/425

If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. *

0/425

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for. *

0/425

Did this job require you to interact with coworkers, the general public, or anyone else?*

YesNo

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or work week.*

0/525

Tell us how much time you spent doing the following physical activities in a typical workday. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day. The example below shows an 8-hour workday with 2 hours standing and walking, and 6 hours sitting (8 hours total).

Activities

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Activities

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle):

Activities

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday.*

0/275

Select the heaviest weight lifted:*

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):*

Did this job expose you to any of the following? Check all that apply.*

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.*

0/275

Explain how your medical conditions would affect your ability to do this job.*

0/275

Provide more information about Job No. 3 listed in Section 2. Estimate hours and pay, if needed.

JOB TITLE NO. 3*

Rate of Pay:*

Per (Check One):*

Hours per Day:*

Days per Week:*

For the job you listed in Job Title No. 3, describe in detail the tasks you did in a typical workday. *

0/540

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.*

0/425

If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. *

0/425

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for. *

0/425

Did this job require you to interact with coworkers, the general public, or anyone else?*

YesNo

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek.*

0/525

Tell us how much time you spent doing the following physical activities in a typical workday. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day. The example below shows an 8-hour workday with 2 hours standing and walking, and 6 hours sitting (8 hours total).

Activities

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Activities

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle):

Activities

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday.*

0/275

Select the heaviest weight lifted:*

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):*

Did this job expose you to any of the following? Check all that apply.*

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.*

0/275

Explain how your medical conditions would affect your ability to do this job.*

0/275

Provide more information about Job No. 4 listed in Section 2. Estimate hours and pay, if needed.

JOB TITLE NO. 4*

Rate of Pay:*

Per (Check One):*

Hours per Day:*

Days per Week:*

For the job you listed in Job Title No. 4, describe in detail the tasks you did in a typical workday. *

0/540

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.*

0/425

If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. *

0/425

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for. *

0/425

Did this job require you to interact with coworkers, the general public, or anyone else?*

YesNo

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek.*

0/525

Tell us how much time you spent doing the following physical activities in a typical workday. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day. The example below shows an 8-hour workday with 2 hours standing and walking, and 6 hours sitting (8 hours total).

Activities

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Activities

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle):

Activities

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday.*

0/275

Select the heaviest weight lifted:*

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):*

Did this job expose you to any of the following? Check all that apply.*

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.*

0/275

Explain how your medical conditions would affect your ability to do this job.*

0/275

Provide more information about Job No. 5 listed in Section 2. Estimate hours and pay, if needed.

JOB TITLE NO. 5*

Rate of Pay:*

Per (Check One):*

Hours per Day:*

Days per Week:*

For the job you listed in Job Title No. 5, describe in detail the tasks you did in a typical workday. *

0/540

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.*

0/425

If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. *

0/425

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for. *

0/425

Did this job require you to interact with coworkers, the general public, or anyone else?*

YesNo

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek.*

0/525

Tell us how much time you spent doing the following physical activities in a typical workday. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day. The example below shows an 8-hour workday with 2 hours standing and walking, and 6 hours sitting (8 hours total).

Activities

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Activities

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle):

Activities

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday.*

0/275

Select the heaviest weight lifted:*

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):*

Did this job expose you to any of the following? Check all that apply.*

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.*

0/275

Explain how your medical conditions would affect your ability to do this job.*

0/275

SECTION 3 - REMARKS

Please provide any additional information you did not give in earlier parts of this report. If you did not have enough space in the prior sections of this report to provide the requested information, please use this space to provide the additional information requested in those sections. Be sure to include the job title number and question to which you are referring. If you add more jobs than the 5 jobs listed, please provide the same information as you did for job titles numbers 1-5 on a separate sheet of paper(s).

Remarks

0/2500

SECTION 4 - WHO IS COMPLETING THIS REPORT

Date Report Completed (MM/DD/YYYY) *

Date

Who is completing this report?*

The person listed in 1.A.Someone else (Complete the information below)

NAME *

Relationship to the Person in 1.A.*

MAILING ADDRESS (Street or PO Box) Include the apartment number, if applicable.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

DAYTIME PHONE NUMBER where we may reach you or leave a message, if needed. Include the area code or IDD and country code if outside the USA or Canada.*

Please enter a valid phone number.

Rows	Job Title (e.g., Cashier)	Type of Business (e.g., Grocery Store)	Dates Worked From (MM/YYYY)	Dates Worked To (MM/YYYY)
1
2
3
4
5
6
7
8
9
10