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Functional Abilities Form (FAF) : To Support A Safe Return To Work

This document is a functional abilities form used to assess a patient's abilities and make recommendations for returning to work. It includes sections on recommendations for returning to work, abilities and limitations in areas like lifting, sitting, standing, and cognitive function, and a physician's assessment and signature.

Uploaded by

Vaibhav Dafale
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
11 views

Functional Abilities Form (FAF) : To Support A Safe Return To Work

This document is a functional abilities form used to assess a patient's abilities and make recommendations for returning to work. It includes sections on recommendations for returning to work, abilities and limitations in areas like lifting, sitting, standing, and cognitive function, and a physician's assessment and signature.

Uploaded by

Vaibhav Dafale
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Functional Abilities Form (FAF)

To support a safe return to work.

Name of Patient Date of Birth SSN

A. RECOMMENDATIONS for RETURN TO WORK


1. Have you discussed return to work with your patient? Yes No
Please explain:

2. Does your patient require assistance or retraining in preparing for return to full duties, etc.? Yes No
Please explain:

3. Recommendations for work hours and start date:

Regular full-time hours effective ______________.

Modified hours effective ______________, _________ hours/day and/or _________ hours/week.

Graduated hours effective ______________, ______ hours/day for_________ week(s), then _______ hours/day for _______ week(s).

4. Recommended date of next appointment to review abilities and/or restrictions:


B. ABILITIES AND LIMITATIONS – Include comments in Section C
5. Walking: Standing: Sitting: Lifting from floor to waist:
Full abilities Full abilities Full abilities Full abilities
Up to 2 hours/day Up to 2 hours/day Up to 2 hours/day Up to 10 lbs.
Up to 4 hours/day Up to 4 hours/day Up to 4 hours/day 10 – 20 lbs.
Other (please specify) Other (please specify) Other (please specify) Other (please specify)

Lifting from waist to shoulder: Stair Climbing: Ladder climbing: Travel to work:
Full abilities Full abilities Full abilities Ability to use Public transit
Up to 10 lbs. 1 - 2 flights at a time None Yes No
10 – 20 lbs. 3 - 4 flights at a time Limited to
Other (please specify) Other (please specify) ___________________ Ability to drive a car
Yes No

Cognitive limitations: Bending/twisting Work above chest/ Forceful or repetitive Pushing/pulling with: R L
Full abilities repetitive movement: shoulder level: R L grasping with: R L Full abilities
Memory Full abilities Full abilities Full abilities None
Concentration None None None Limited to
Fatigue Limited to Limited to Limited to
Interaction with others ___________________
Other (please describe) ___________________ ___________________ __________________

Kneeling or squatting: Operating motorized equipment (i.e. forklift): Other:


Full abilities Full abilities
None None
Limited to Limited to ___________________
___________________
C. COMMENTS – Abilities and Limitations
6. Additional comments on abilities and limitations listed above:

7. From the date of this assessment, the abilities and limitations noted above will expire on:

D. PHYSICIAN’S INFORMATION
Physician’s Name (please print): Physician’s Signature: Date:

Email:
Degree/Specialty: Address: Phone:

Fax:
Work Connections, University of Michigan, Argus II Bldg., 400 S. Fourth Street, Ann Arbor MI 48103-4816
Ann Arbor: (734) 615-0643 | Toll-free: (877) 869-5266 (UMWKCON) | Fax: (734) 936-1913 | E-mail: [email protected]

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