Functional Abilities Request Letter

 

(Date of issue)
 

Company Name

Dear (Physician name),

As, Ms./Mr (Employee Name) employer, we are committed to properly assessing her/his functional restrictions to ensure she can be properly accommodated.

Our intention is to ensure that (Employee name) makes a safe return to work, and to ensure that they can continue their employment with Company Name in a meaningful way with appropriate allowances for reasonable accommodation.

Company Name requires a completed Functional Abilities Form which accurately assesses the abilities of (Employee name) so that we can ensure that their job duties are assigned appropriately. We have attached a copy of (Employee name)’s current job description.

If you require additional room to answer the questions, I would ask that you please add your responses to a separate sheet of paper. Your attention to the above is appreciated, and please contact me if you have any questions.

Sincerely,

 

(Signature)
(Name)
(Position, title, and department)

 

 

 

Functional Abilities Form – Non-Occupational Injury/Illness

Note to medical provider: Please completely fill out the applicable sections of this form to assist us in determining appropriate and safe modified duties. Thank you.

Employee Name: __________________________

☐Initial Form ☐Follow-up Form

 

I authorize the release of the information below to my employer.

 

Employee Signature: _________________________ Date: ____________________

Please return this form by fax or e-mail, or return with employee.
 

To be completed by Company Name:

General Information

Current Position:______________________________________________________

☐ A Job Description or Position Summary is attached

 

 

Date of Assessment: ________________________

 

Date of Next Appointment: ________________________

 

Injury/Illness Area: ________________________

 

☐ Patient is capable of returning to work with no restrictions.

☐Patient is capable of returning to work with restrictions.

Complete Recovery Expected: Yes☐ No☐

 

Anticipated date, return to full duties_____________________

Capabilities (applicable categories must be completed)

Standing:

☐Full abilities

☐Up to 15 minutes

☐15-30 minutes

☐Other (specify):

 

 

 

 

 

 

Sitting:

☐Full abilities

☐Up to 30 minutes

☐30 minutes – 1 hour

☐Other (specify):

Walking

☐Full abilities

☐Up to 30 minutes

☐30 minutes - hour

☐ Other (specify):

Lifting from floor to waist:

☐Full abilities

☐Up to 5 pounds

☐5-15 pounds

☐Other (specify):

 

 

 

 

 

Lift above waist to shoulder:

☐Full abilities

☐Up to 5 pounds

☐5-15 pounds

☐Other (specify):

Lifting above shoulder

☐Full abilities

☐Up to 5 pounds

☐5-15 pounds

☐Other (specify):

Limitations (applicable categories must be completed)

☐Bending or Twisting:

 

☐Repetitive Motion of:

 

☐Pushing or Pulling:

 

☐ Grip:

☐Writing, Typing, Speaking or Hearing, (specify):

 

 

 

☐Potential side effects from medication (please specify, do not include names of medications):

 

 

Cognitive Capabilities (ONLY to be filled out if directly applies to reason for absence )

Work With Others

☐ Yes ☐ No

 

Manage Emotions

☐ Yes ☐ No

Concentrate on Tasks

☐ Yes ☐ No

Exercise Appropriate Behaviour

☐ Yes ☐ No

Other (specify):

 

 

 

□ Potential side effects from medication (please specify, do not include names of medications):

 

If you have answered "No" to any of the above has the employee been referred to a medical specialist to address the psychological concerns?

☐ Yes ☐ No

 

The Employer has a modified duties program in place. Have you discussed modified duties as part of the rehabilitation/treatment plan?

________________________________________________________________________________________________________________________________________________________

______________________________________________________________________

 

Without disclosing any specific medical conditions or diagnoses, we would ask that you please answer the following questions and provide sufficient additional details as may be necessary:

 

1. Are there any physical restrictions or limitations on Employee Name ability to return to work?

 

 

 

 

2. Are there any restrictions on the number of hours per day, or days per week, that Employee Name can work?

 

 

 

 

3. Does Employee Name require frequent breaks? If so, please elaborate on the frequency and length of breaks.

 

 

 

 

4. Is Employee Name able to attend and perform work at the Firm’s physical office location at Address of job site?

 

 

 

 

5. A copy of Employee Name job description is attached. In your opinion, are there any restrictions on the tasks as set out in Ms. Catarino’s job description(s)?

 

 

 

 

 

Additional Comments:

________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

 

Medical provider's signature :

____________________________________

Date:

____________________________________

Medical provider's name (print):

____________________________________

Profession:

____________________________________

 

Medical Office Stamp

 

Forward by email or confidential fax to: (Insert Company details)