Scribd
Upload
4 views

FAF Non Work Related - blank

Uploaded by

neeraj kapoor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
4 views

FAF Non Work Related - blank

Uploaded by

neeraj kapoor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

FUNCTIONAL ABILITIES FORM

For Early and Safe Return to Work

A. WORKER & EMPLOYER INFORMATION


Section A to be completed by employer and/or worker
Worker's Last Name First Name Address (No., Street, Apt./Unit)

Telephone Gender City/Town Prov. Postal Code

Day Month Year Day Month Year


Date of Birth: Date of Accident / Awareness of Illness:
Type of job at time of accident (where available, please attach description of job activities) Area(s) of injury(ies)/ilness(es)
1.
Day Month Year
2. Have the worker and employer discussed Return to Work If "No", will be discussed on:
Employer Contact Name Position Telephone
3.

EMPLOYER INFORMATION
Employer's Name Full Address (No., Street, Apt./Unit)

City/Town Prov. Postal Code Employer Telephone Employer Fax

B. WORKER'S SIGNATURE
By completing & signing below I am authorizing any health professional who treats me to provide me, my employer (Commissionaires Great Lakes ) with
information regarding my functional abilities for my current injury and/or illness in order to ensure a safe return to work.
Worker Signature Day Month Year
Date:

C. HEALTH PROFESSIONAL'S INFORMATION


Health Professional Name (Please Print) Profession Signature

Address (No., Street, Apt./Unit) City/Town Prov. Postal Code

Telephone Day Month Year


Date:
Page 1 of 2
FUNCTIONAL ABILITIES FORM
For Early and Safe Return to Work
Worker's Last Name First Name Claim No. (if known)
0 0 0
D. WORKER ASSESSMENT DATE & STATUS
Sections D through F are to be completed by the Health Care Professional to
identify the patient's overall abilities and restrictions
1 Date of Day Month Year 2 Please check one:
Assessment: Patiient is capable of Patient is capable of Patient is physically
returning to work with no returning to work with unable to return to work
restrictions restrictions. Complete at this time. Complete
sections E & F section F

E. WORKER ABILITIES and/or RESTRICTIONS


1. Please indicate Abilities that apply. Inlcude additional details in section 3
Walking: Standing: Sitting: Lifting from floor to waist:
Full Abilities Full abilities Full abilities Full abilities
Up to 100 metres Up to 15 minutes Up to 30 minutes Up to 5 kilograms
100 - 200 Metres 15 - 30 minutes 30 minutes - 1 hour 5 - 10 kilograms
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 Ability to drive a
Up to 5 kilograms Up to 5 steps 1 - 3 steps public transit car
5 - 10 kilograms 5 - 10 steps 4 - 6 steps Yes Yes
Other (please specify) Other (please specify) Other (please specify) No No

2. Please indicate Restrictions that apply. Inlcude additional details in section 3


Bending/twisting Work at or Chemical Environmental Limited use of hand(s):
repetitive above exposure exposure to: Left Right
movement of shoulder to: (i.e. heat, cold, Gripping
(please specify) activity: noise or scents) Pniching
Other (please specify)

Lminited pushing/pulling with: Operating motorized Potential side effects Exposure to vibration:
Left Arm equipment: (i.e. forklift) from medications Whole body
Right Arm (specify). Don't Hand/Arm
Other (please specify) include names of
3. Additional Comments on Abilities and/or Restrictions

4. From the date of this assessment, the above will apply for approximately: 5. Have you dicussed Return to Work with your patient?
1 - 2 days 3 - 7 days 8 - 14 days 14+ days Yes No

6. Recommendations for work hours and start date: Day Month Year
Regular full-time hours Modified hours Graduated hours Start Date:

F. DATE OF NEXT APPOINTMENT


Day Month Year
Recommended date of next appointment to review Abilities and/or Restrictions:

I have provided this completed Functional Abilities Form to: Worker and/or Employer
Page 2 of 2

You might also like