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(TOOL ICON)
I.
COLORADO AGRABILITY
AGRICULTURAL WORKSITE
(BARN ICON)
ASSESSMENT TOOL
PERSONAL DATA
Name: _____________________________
Address: ___________________________
City: ___________________ State: ______
Phone: _____________________________
Date of Birth: __________ Sex: ________
Date: _______________________
County: ________________________________
Zip Code: _______________________________
Spouse: _______________________
Disability/Injury:
________________________________________________________________________________
_______________________________________________________________
Please circle those words that describe any major or minor physical limitations experienced
by you:
-Hearing -Walking
-Carrying
-Crawling
-Smelling
-Running
-Pushing -Balancing
-Tasting
-Jumping
-Pulling
-Other ________________________________
-Breathing
-Climbing
-Twisting
_______________________________________
-Sensation
-Grasping
-Stooping
-Standing
-Lifting
-Kneeling
II.
GENERAL FARM/RANCH DATA
A.
Occupation:
( ) Full time farmer/rancher
( ) Part time farmer/rancher
( ) Dependent of farm/ranch family
( ) Farm/ranch employee
( ) Ag Business (type)_________________________________________
( ) Other:___________________________________________ Years/Months:_________________
B.
Co-workers/Family Members that Assist Client with Tasks (name, relations, and tasks)
_______________________________________________________________________________
_______________________________________________________________________________
C.
Type and Size of Operation: (Please check the type of livestock or crops, size of herds,
number of acres).
Livestock: _____________________________________________________________________
_______________________________________________________________________________
Crops: _________________________________________________________________________
_______________________________________________________________________________
Acres: _________________________________________________________________________
Colorado AgrAbility Agricultural Worksite Assessment
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III.
IV.
ACCESSIBILITY
A.
Problems in maneuvering around farm terrain:
( ) Hilly
( ) Rocky
( ) Wooded
( ) Muddy ( ) Soft, gilled
( ) Loose gravel
( ) Clay
( ) Low spots
( ) Other/Detailed description:______________________________________________________
_______________________________________________________________________________
B.
Farm shop accessibility problems:
( ) Steps
( ) Reaching stationary tools
( ) Bench too low
( ) Heavy doors
( ) Protruding obstacles
( ) Heat/cooling inadequate
( ) Poor lighting
( ) Poor ventilation
( ) Communication w/others
( ) Narrow door
( ) Bench too high
( ) Cluttered/trip hazards
( ) Other/Detailed Descriptions:_____________________________________________________
_______________________________________________________________________________
C.
Machinery storage problems:
( ) Opening door to machinery storage areas
( ) Storage areas too small for hitching, servicing, maintenance of equipment
( ) Inability to enter machinery storage area independently
( ) Difficulty in ambulating and maneuvering on floor surface
( ) Other/Detailed Descriptions:_____________________________________________________
_______________________________________________________________________________
D.
Livestock handling facilities (accessibility problems):
( ) Narrow doors
( ) Narrow aisles
( ) Pens not accessible
( ) Opening barn door ( ) Poor ventilation
( ) Unloading/loading chutes
( ) Opening gates
( ) Protruding obstacles
( ) Squeeze chutes not accessible
( ) Reaching animals
( ) Steps
( ) Muddy feed lot
( ) Other/Detailed desciptions:_____________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
GENERAL FARM/RANCH MAINTENANCE
(Problems with use of tools and maintenance)
A.
Problems with hand tool use:
( ) Sockets/ratchets
( ) Knife
( ) Hand rake
( ) Wrenches
( ) Hand saw
( ) Pullers/special tools
( ) Hammers
( ) Hand drills
( ) Fence stretchers
( ) Screwdrivers
( ) Grease gun
( ) Cables/winches
( ) Pliers/Vise
( ) Hand air pump
( ) Pry bar
( ) Punch/chisels
( ) Clamps
( ) Tap and die set
( ) File
( ) Hoe
( ) Shovel
( ) Axe/maul
( ) Staple gun
( ) Wire nippers
( ) Other/Detailed description:______________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
B.
Problems with materials handling use:
( ) Nuts/bolts
( ) Glue
( ) Sandpaper
( ) Nails/screws/staples ( ) Wire
( ) Welding rod
( ) Lumber
( ) Paint
( ) Lubricants
( ) Other problems with materials handling:__________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Colorado AgrAbility Agricultural Worksite Assessment
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V.
C.
Problems with Power tools:
( ) Power saws
( ) Power drill
( ) Welder
( ) Impact wrench
( ) Sander
( ) Pnuematic tools
( ) Other/Detailed description:______________________________________________________
_______________________________________________________________________________
D.
Maintenance/Repair tasks (problem areas):
( ) Fencing
( ) Gates ( ) Feed systems
( ) Painting
( ) Roofing
( ) Doors ( ) Waste removal ( ) Home
Other/Detailed description:_________________________________________________________
__________________________________________________________________________________
EQUIPMENT AND MACHINERY USE
Problem areas: no cab, no heating/cooling, no 2-way radio, no rearview mirror, inability to
mount/dismount, problem with seating, other.
Problem with controls: steering, clutch, brakes, throttle, operating switches, transmission
shifter, power take-off, hydraulic levers, differential lock, controls of 2-way, other.
Problems with tasks: hitching/unhitching, fueling, changing oil/filters, lubrication, repairs,
changing tires, connecting/disconnecting hydraulics or PTO, adjust/change belts, replace
sickle sections and chains, cleaning out clogged machinery, other.
Problems with implements: replacing parts, adjusting equipment, lubrication, lowering or
raising, lifting tongues, adjusting machinery, hooking up, other.
A.
VI.
Problems with Tractors/Combines/Self-Propelled Harvesters
1.
Make ______________ Model _________________ Age __________________________
Problems:_________________________________________________________________
___________________________________________________________________________
2.
Make ______________ Model _________________ Age __________________________
Problems:_________________________________________________________________
___________________________________________________________________________
3.
Make ______________ Model _________________ Age __________________________
Problems:_________________________________________________________________
___________________________________________________________________________
MANUAL PRODUCTION (problem areas)
A.
Crops
( ) Lifting, carrying bales
( ) Access to crop storage ( ) Climbing storage bins
( ) Operating equipment
( ) Moving auger
( ) Scooping
( ) Maneuvering
( ) Unloading/loading
( ) Cultivating
( ) Soil preparation
( ) Soil testing
( ) Hazardous materials
( ) Fertilizers
( ) Herbicides
( ) Planting
( ) Irrigating
( ) Spraying
( ) Pruning
( ) Transplanting
( ) Harvesting
( ) Weeding
( ) Trimming
( ) Picking
( ) Other/Detailed description:
__________________________________________________________________________________
__________________________________________________________________________________
B.
Livestock
( ) Operate feeding system
( ) Scooping
Colorado AgrAbility Agricultural Worksite Assessment
( ) Lifting/carrying buckets
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( ) Pushing grain carts ( ) Pulling feed wagon
( ) Shoveling
( ) Sorting
( ) Catching livestock
( ) Vaccinating
( ) Loading/unloading ( ) Waste removal ( ) Artificial insemination
( ) Breeding
( ) Ear tagging
( ) Semen collection
( ) Branding
( ) Processing
( ) Dairy tasks
( ) Hoof trimming
( ) Dehorning
( ) Castration
( ) Clipping/trimming ( ) Washing
( ) Butchering
( ) Pelting
( ) Packaging
( ) Storing
( ) Poultry tasks
( ) Hog tasks
( ) Other/Detailed description
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
VII.
FARM MANAGEMENT
A.
Problem Areas and why:
( ) 1. Maintaining business records__________________________________________________
_______________________________________________________________________________
( ) 2. Performing sales and purchases________________________________________________
_______________________________________________________________________________
( ) 3. Finding/training labor________________________________________________________
_______________________________________________________________________________
( ) 4. Supervision__________________________________________________________________
_______________________________________________________________________________
( ) 5. Communicating instructions___________________________________________________
_______________________________________________________________________________
( ) 6. Book keeping/payroll_________________________________________________________
_______________________________________________________________________________
( ) 7. Herd/crop management_______________________________________________________
_______________________________________________________________________________
( ) 8. Other/Detailed description____________________________________________________
_______________________________________________________________________________
VIII. PRIMARY GOALS OF CLIENT
A.
Check the following goal areas concerning worksite adaptations needed.
( ) Improve the overall mobility or accessibility around farmyard, building, and fields.
( ) Improve livestock-handling related to feeding methods, health care needs, waste
removal, and building sanitation.
( ) Improve ability to effectively and safely use equipment and machinery (includes
access, operating, maintaining, hitching)
( ) Improve ability to perform general maintenance activities around farm (includes use
of hand tools, power tools, and handling materials)
( ) Improve ability to manage farm/ranch operation successfully (includes maintaining
business records, sales, purchases, labor management, breeding records, etc.)
( ) Other goals/description_________________________________________________________
__________________________________________________________________________________
B.
Additional Funding/Resources Needed? Yes or No
Contributors:
( ) Self/Family
( ) DVR
( ) VA
( ) Private
( ) Combination of above
( ) Other_________________
C.
Additional Referrals Made? Yes or No
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To:_______________________________________________________________________________
__________________________________________________________________________________
IX.
SUMMARY, RECOMMENDATIONS, AND PLAN
A. Summary:
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B. Recommendations:
_______________________________________________________________________________________
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C. Plan:
_______________________________________________________________________________________
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_____________________________________________.
Reporting Person:
Name:
Title:
Reporting Person:
Name:
Title:
Colorado AgrAbility Agricultural Worksite Assessment