B.06.05 Attachment 8 - Crane Operator and LHE Examination Form.pdf

Employee Name: ________________________________________Date of Birth: ______________

Classifications:

*USACE Class I Operator – designated by position to operate mobile cranes, bridge cranes, gantry cranes, hammerhead cranes, etc.

*USACE Class II Operator – designated by position to operate equipment used for lifting and lowering continually guided loads, specifically equipment used to hoist/lift personnel. This activity is considered a Critical Lift and as such, requires the same physical qualifications as a Class I operator.

Choose applicable category, ONLY (1): Crane Operator, Class I or Crane Operator, Class II

Vision: The operator meets at least 20/30 Snellen in one eye and 20/50 in the other or a combined binocular acuity of at least 20/40 with or without corrective lenses. Operator meets the vision requirement for the position:

Operator meets the vision requirement for the position:

YES NO

With or without corrective lenses?

With Without

Depth Perception and Field of Vision: The operator has normal, field of vision, reaction time, manual dexterity, coordination and no tendencies to dizziness or similar undesirable characteristics. NOTE:

depth perception shall be no more than 70 seconds of Arc and a field of vision of at least 70 degrees in the horizontal median in each eye.

Operator meets the depth perception and field of vision requirements for the position:

YES NO

Hearing: The operator has average hearing in the better ear ≤ 40 dB at 500/1000/2000/3000/4000 Hz with or without a hearing aid.

Operator meets the hearing requirements as described above? YES NO Does the Operator meet the requirement With or Without hearing aids?

Does the Operator have hearing aids for the Right Left or Both ear(s)? NA If you were not able to perform an aided hearing evaluation, should the Operator be referred for this type of evaluation done?

YES NO

Distinguish Colors: Regardless of position, the operator has the ability to recognize the colors of traffic signals and devices identifying the standard red, amber and green;

Operator meets the distinguishing colors requirement for the position:

YES NO

Crane Operator and Load Handling Equipment (LHE) Examination Form

October 2020

Overall stamina: Operator has sufficient strength, endurance, agility, coordination, manual dexterity, and speed of reaction to meet the demands of equipment operation.

Operator meets the stamina requirement for the position:

YES NO

Overall physical finding: Operator has no tendencies to dizziness or similar undesirable characteristics; does not have any evidence of physical defects, emotional instability that could render a hazard to the operator, others, or safe operation of the equipment, or evidence that the operator is subject to seizures or loss of physical control shall be sufficient reason for disqualification. (In such cases, specialized medical tests may be required to evaluate these conditions and determine their impact)

Operator meets the overall physical requirements for the position:

YES NO

SECTION 2 - Physician’s Medical Certification: Please inform the Operator of the examination findings noted below.

Operator Name Printed: _____________________________________

I, as the examining Physician, certify that the above mentioned Operator has been examined and the following findings are noted:

1. Operator passed without limitations

2. Operator passed with the following limitations:

Only when wearing corrective lenses Only when wearing hearing aids

3. Operator passed with the following waiver: I, as the attending physician, examined the aforementioned operator applicant/incumbent and within medical certainty I find the applicant/incumbent at no greater risk than the general population as a result of any physical, mental, or organic defects, and certify that the Operator can safely operate a crane/derrick with the diagnosis described in the attached Statement.

4. Operator did not pass all physical requirements as noted above.

5. Decision deferred, additional documentation needed. Please provide required documentation:_______________________________________________________

Physician Signature: _________________________________________ Date: ____________

Questions in reference to the above instructions may be directed to Contracting Officer’s Representative (COR) referenced in Performance Work Statement

Crane Operator and Load Handling Equipment (LHE) Examination Form

October 2020