Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 77 of 53 8 I M R T W PH YSI C I A N S PH YSI C A L A SSESS M EN T F OR M Doc u m e n t Identif icat ion F R M 022 P age Nu m b e r 1 of 2 Doc u m e n t C r e ation Dat e J une 30 2014 Im p le m e n tat ion Dat e S e ptembe r 1 2 014 I M RT W P hy s i cians P hy s ical As s es s ment Re port Emp loyee s N ame D at e Is emp loyee f i t f or re gu la r d u t ies as p er e n c lose d Ph ys ic al D e man d s An alys is Y es No I f N O t h e emp l oyee is m ed ic ally a b l e t o w or k w it h limi t at i on s or re s t rict i o n s as o f Th e a p p r oximat e d u rat io n o f t h e limit a t io n sr es t r ic t ion s is f el t t o b e D ays 2 D ays 2 t o 6 W ee k s 6 Wee k s t o 3 M onth s A ct i vi ti e s Phy si cal De m a n d s W or ke r a b l e t o p e r f or m th e f o l l o w i n g d u ti e s Ye s No Lif t or c arry u p t o 45 Kg 10 lb s Lif t or c arry u p t o 91 Kg 20 lb s Lif t or c arry u p t o 23 Kg 5 0lb s Lif t or c arry u p t o 45 Kg 1 00 lb s W or ke r a b l e t o p e r f or m th e f o l l o w i n g d e m a n d s Ye s No Pu sh or p u ll 23 Kg 50 l b s Pu sh or p u ll 45 Kg 10 0lb s Pu sh or p u ll 45 Kg 10 0 l b s W or ke r a b l e t o p e r f or m th e f o l l o w i n g d e m a n d s Ye s No B e ab le t o c limb l ad d er s Us e st airw ays Op er at e self p owere d eq u ip me n t Wor k st an d in g Wor k seat e d Or c om b in a t io n W or ke r a b l e t o w a l k Ye s No 15 M et e rs 5 0 f ee t 90 M e t er s 30 0 f ee t Lon ger d ist a n c es o n eve n su r f aces Lon ger d ist a n c es o n u n e ven su r f aces Ot h er A ny other re s t r i ct i ons or l i m i t at i ons