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 ofan individual or family

member of the individual, except as specificallyallowed by this law. To complywith this law, we are

asking that you not provide anygenetic informationwhen responding to this request for medical

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

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

familymember sought or received genetic services,and genetic information ofafetus carried byan

individual or an individual'sfamilymember or an embryo lawfullyheld byan individual or familymember

receiving assistive reproductive services.

A.POSTURAL LIMITATIONS:

Continuously Frequently Infrequently Never

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

Sitting GGGG

Standing GGGG

Walking GGGG

BendingGGGG

Climbing GGGG

Reaching GGGG

Squatting/Stooping GGGG

Crawling GGGG

Kneeling GGGG

B.PHYSICAL EXERTION LIMITATIONS:

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

Lifting GGGG

CarryingGGGG

Pushing/PullingGGGG

C.MANIPULATIVE LIMITATIONS:

Unlimited Limited

Handling (gross) GG

Fingering (fine) GG

Feeling (skin receptors)GG

D.MENTAL LIMITATIONS:

Unlimited Limited

UnderstandingGG

Remembering GG

Sustained concentrationGG

Following through on instructionsGG

Decision making GG

Responding appropriately to workplace pressuresGG

Receiving supervisionGG

Relating to co-workers GG

E.VISUAL/COMMUNICATIVE LIMITATIONS:

Unlimited Limited

Acuity (near/far); Depth; Color; FieldGG

Hearing GG

Speaking GG

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 SignatureDate

____________________________________________________________________________

Name of Practice Type of Practice

____________________________________________________________________________

AddressTelephone