Fillable Printable Functional Capacity Assessment

Functional Capacity Assessment

RELEASE OF INFORMATION

I, _________________________________, hereby authorize _________________________, physician/

(Please PRINT) (Please PRINT)

practitioner, to furnish written information to ______________________________________________,

my employer, regarding my residual functional capacity, any limitations or restrictions on my ability to

perform the functions of my position and any devices, equipment, or accommodations I require to enable

me to perform these functions.

Employee’s Signature ____________________________________________ Date _________________

FUNCTIONAL CAPACITY ASSESSMENT

Physician/Practitioner - Please confine your completion of this form to only those elements that are

pertinent to the employee’s ability to perform the essential functions of his/her job. Explain any limitations

in Section G.

Genetic Information Nondiscrimination Act of 2008 Notice

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities

covered by GINA Title II from requesting or requiring genetic information of an individual or family

member of the individual, except as specifically allowed by this law. To comply with this law, we are

asking that you not provide any genetic information when responding to this request for medical

information. “Genetic Information” as defined by GINA includes an individual's family medical history, the

results of an individual's or family member's genetic tests, the fact that an individual or an individual's

family member sought or received genetic services, and genetic information of a fetus carried by an

individual or an individual's family member or an embryo lawfully held by an individual or family member

receiving assistive reproductive services.

A. POSTURAL LIMITATIONS:

Continuously Frequently Infrequently Never

(4-6 hrs./day) (2-6 hrs./day) (0-2 hrs./day)

Sitting G G G G

Standing G G G G

Walking G G G G

Bending G G G G

Climbing G G G G

Reaching G G G G

Squatting/Stooping G G G G

Crawling G G G G

Kneeling G G G G

B. PHYSICAL EXERTION LIMITATIONS:

Up to 10 lbs. 10 lbs. to 25 lbs. 25 lbs. to 50 lbs. Over 50 lbs.

Lifting G G G G

Carrying G G G G

Pushing/Pulling G G G G

C. MANIPULATIVE LIMITATIONS:

Unlimited Limited

Handling (gross) G G

Fingering (fine) G G

Feeling (skin receptors) G G

D. MENTAL LIMITATIONS:

Unlimited Limited

Understanding G G

Remembering G G

Sustained concentration G G

Following through on instructions G G

Decision making G G

Responding appropriately to workplace pressures G G

Receiving supervision G G

Relating to co-workers G G

E. VISUAL/COMMUNICATIVE LIMITATIONS:

Unlimited Limited

Acuity (near/far); Depth; Color; Field G G

Hearing G G

Speaking G G

F. NON-PHYSICAL EXERTION LIMITATIONS:

Pain (frequency; degree; objective signs)

Environmental restrictions (exposure to dust, fumes, smoke, heights, heat/cold, noise; other)

Rest periods (frequency/duration)

Side effects of medication

G. REMARKS:

(Please use this space to explain or clarify any of the preceding information.) Describe any specific

limitations or restrictions for any of the above categories and list any assistive devices, equipment, or

accommodation the employee requires to perform his or her job:

___________________________________________________ _________________________

Physician’s/Practitioner’s Signature Date

___________________________________________________ _________________________

Name of Practice Type of Practice

___________________________________________________ _________________________

Address Telephone