Date of Test:

-- mm/dd/yy

          Applicant Information:

First Name
Last Name
Date of Birth	(mm/dd/yyyy)
Sex	Male Female
Height (inches)
Weight (lbs)
SS Number

          Company Name and Position:

Company Name	Helmerich & Payne, Inc.
Position	Floorhand
Rig Number

          PDC Level:

Sedentary Light Medium Heavy Very Heavy

Hand Dominance:

          Right Left

Cardiovascular Status:

Resting Heart Rate
15-sec Pulse after Step Test
Cardiovascular Status
Blood Pressure
Release Required?	Yes No

          Grip Testing

Grip Test Average - Right

Grip Test Average - Left

Range of Motion

Cervical Flexion

Cervical Extension

Cervical SB - Right

Cervical SB - Left

Cervical Rotation - Right

Cervical Rotation - Left

Lumbar Flexion

Lumbar Extension

Lumbar SB - Right

Lumbar SB - Left

Dynamic Lifting Tests

Floor to Knuckle Lift

Reason F-K Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

12" to Knuckle Lift

Reason 12"-Kn Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

Knuckle to Shoulder Lift

Reason Kn-Sh Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

Shoulder to Overhead Lift

Reason Sh-OH Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

Body Mechanics

Good Fair Poor Unacceptable

Education given regarding body mechanics?

Yes No

Specific Abilities and Functions Evaluation (SAFE)

SAFE Activity #1 Description

Subject will lift 55 lbs. lubricant pails, measuring 5 gallons, single handed, from the floor, carry it 25 feet, and place on a level surface at a height of 38", and then return to its original location. Repeat 10 times.

Body Mechanics

Good Fair Poor Unacceptable

Post-Activity Heart Rate

SAFE #1 Results

Capable Not Capable

SAFE Activity #2 Description

Subject will pick up a 12 lbs. sledgehammer off of the ground and 12" from the body, turn 45 degrees, and then climb up a ladder to a height of 30', and then return the sledgehammer to its original location. Repeat 10 times.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

SAFE #2 Results

Capable Not Capable

SAFE Activity #3 Description

Subject will lift a 100 lbs. standard "mud Mixing Material" sack, from 6" off the floor, carry it 25 feet, and place on a level surface at a height of 38", and then return to its original location. Repeat 10 times.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

SAFE #3 Results

Capable Not Capable

SAFE Activity #4 Description

Subject will stand, with arms extended 24" from body, at shelf height of 38", and sort assorted nuts & bolts over a 5:00 time.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

SAFE #4 Results

Capable Not Capable

SAFE Activity #5 Description

N/A

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

SAFE #5 Results

Capable Not Capable

Applicant's Conduct

Cooperative      Uncooperative              

Overall Test Results

Pass Fail - Medical Risk Fail - Essential Functions Fail - Falsified Information Hold - Risk Factors Identified

Additional Comments

Clinician Name