Claim No Claimant Name Date Of Injury Adjuster Date

claim no: claimant name: date of injury: adjuster: date requested: estimated functional capacity evaluation sedent

Claim No:
Claimant Name:
Date of Injury:
Adjuster:
Date Requested:
ESTIMATED FUNCTIONAL CAPACITY EVALUATION
SEDENTARY WORK: lift 10# maximum and occasionally carry small objects
LIGHT WORK: lift 20# maximum; frequently lift/carry up to 10#
MEDIUM WORK: lift 50# maximum; frequently lift/carry up to 25#
HEAVY WORK: lift 100# maximum; frequently lift/carry up to 50#
VERY HEAVY WORK: lift in excess of 100#; frequently lift/carry 50#
I WOULD ESTIMATE THIS PERSON TO BE ABLE TO:
Never
Occasionally
(1-33%)
Frequently
(34-66%)
Continuously
(67-100%)
Resulting from the Industrial Event (Yes/No)
1. LIFT:
a. up to 10#
b. 11 - 24#
c. 25 - 34#
d. 35 - 50#
e. 51 - 74#
f. 75 - 100#
2. CARRY:
a. up to 10#
b. 11 - 24#
c. 25 - 34#
d. 35 - 50#
e. 51 - 74#
f. 75 - 100#
3. PERFORM THE FOLLOWING TASKS:
Push/Pull – Seated
Push/Pull – Standing
Bend
Squat
Crawl
Climb
Reach above shoulder level
4. ASSUMING AN 8-HOUR WORKDAY WITH TWO 15-MINUTE BREAKS AND A HALF
HOUR MEAL BREAK, I WOULD EXPECT THIS PERSON TO BE ABLE TO:
Circle number of hours for each activity. NOTE: Total does not have to
equal 8 hours.
Activity
Number of Hours
Continuously
With Rests
Sit
1
2
3
4
5
6
7
8
¨
¨
Stand
1
2
3
4
5
6
7
8
¨
¨
Walk
1
2
3
4
5
6
7
8
¨
¨
Alternately Sit/Stand
1
2
3
4
5
6
7
8
¨
¨
5. CAN PERSON USE HANDS FOR REPETITIVE ACTIONS SUCH AS:
Simple Grasping
Firm Grasping
Fine Manipulating
Right:
Yes ¨
No ¨
Yes ¨
No ¨
Yes ¨
No ¨
Left:
Yes ¨
No ¨
Yes ¨
No ¨
Yes ¨
No ¨
Estimated Grip Strength: Right: # Left: #
6. CAN PERSON USE FEET FOR REPETITIVE MOVEMENTS AS IN OPERATING FOOT
CONTROLS?
Right (Alone)
Left (Alone)
Both (Simultaneously)
Yes ¨
No ¨
Yes ¨
No ¨
Yes ¨
No ¨
7. ANY RESTRICTIONS OF ACTIVITIES INVOLVED?
Activity
None
Mild
Moderate
Total
Unprotected Heights
Being around moving machinery
Exposure to marked changes in
temperature and humidity
Driving automotive equipment
Exposure to dust; fumes; gases
8. CAN PERSON NOW RETURN TO FORMER JOB? Yes ¨ No ¨
If not, can person return to other work according to restrictions
defined above? Yes ¨ No ¨
If person cannot return to any work at this time, give estimated date
for return to work:
Can the person work full-time? Yes ¨ No ¨
If not, can the person work part-time? Yes ¨ No ¨
If person can work part-time but not full-time, please estimate
schedule, in hours per day and days per week:
Disability rating (if applicable): %
9. COMMENTS:
Physician Name:
Address:
City, State, Zip:
Telephone:
Field of Specialty:
License No.:
Signature:
Date:
w/s: Forms/FMLA/FMLA- Functional Capacity Eval
4/1/02