BACK Company EMPLOYEE QUESTIONNAIRE DATE AVAILABLE * APPLICANT NAME * NEW NEW UPDATE CONTACT # * Language E B/L S/E % Other Language: TYPE OF WORK * PAY RATE $ * SHIFTS AVAILABLE * 1 2 3 OVER TIME * Yes No WEEKENDS * Yes No Select Options Long-term Short-term School Second Job Hours: REFERRED BY Will you submit to a drug test? * Yes No The essential functions for most positions include working 8-12 hour shifts 5 or more days a week. Can you perform tasks that involve repeatedly transporting heavy objects, squatting, bending, stacking, twisting, reaching, and shrink-wrapping pallets? * Yes No In the course of an 8-hour day, one can expect to repeatedly transport boxes weighing up to 40 pounds. Are you able to repeatedly transport such items? * Yes No How many pounds? * 5-10 11-20 21-39 40+ Lbs Can you work in a facility where the work environment that is hot or refrigerated? * Yes No Can you work in a fast-paced environment where the temperature is hot, and you are required to perform task that involve folding heated items such as bedding or towels? * Yes No In the course of an 8-hour day, one can expect to repeatedly scan or ticket items. Are you able to repeatedly use an RF scanner gun or ticketing gun? * Yes No How do you prefer to work? * Individually With others Both Are you able to work in a fast-paced environment? * Yes No While on assignment are you able to perform tasks that involve using repetitive movements? * Yes No While on assignment can you perform tasks that require you to stand for long periods of time? * Yes No Are you sensitive to chemical fumes or air particles? * Yes No Have you been terminated for any cause? * Yes No Why did you leave your last job? * One Two Three When was your last day worked? * Do you have the following equipment? * Steel Toe Work Boots Safety Back Belt Non-Slip Boots Work exp. / Notes * Captcha
