Fillable FAF 2647A1 (University of Guelph)

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FAF 2647A1 (University of Guelph)

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Functional Abilities Form
for Planning Early and Safe Return to Work
Health Professionals, please use this form ONLY when requested by an employer or worker.
The purpose of this form is to identify your patient's overall functional abilities and work
restrictions that will assist his/her return to suitable work.
Please promptly complete and return pages 2 and 3 of this form to the worker or employer
to assist the workplace parties in planning an early and safe return to work.
PLEASE ENSURE YOUR BILLING INFORMATION IS NOT GIVEN TO THE WORKER OR EMPLOYER.
Authority to Release Information
Section 37(3) of the Workplace Safety and Insurance Act, 1997 provides the legal authority for health professionals
to give the Workplace Safety and Insurance Board (WSIB), the injured worker and the employer such information as
may be prescribed concerning the worker's functional abilities.
When completing this report, please print in black ink.
Worker and/or employer should complete Sections A and B of this report. If your patient needs assistance,
please help. Please submit this report even if Section A is not fully completed.
Information about your responsibilities can be found on Page 4.
The WSIB will pay health professionals for completing this form.
Mail to:
Workplace Safety and Insurance Board
200 Front Street West
Toronto, ON M5V 3J1
Fax to:
416-344-4684
or 1-888-313-7373
OR
A guide to completing this form is available at www.wsib.on.ca
2647A (07/06)
...go to form
print
Mail to:
200 Front Street West
Toronto ON M5V 3J1
or Fax to:
416 344-4684
OR 1-888-313-7373
Functional Abilities Form
for Planning Early
and Safe Return to Work
Claim No.
FAF
Please PRINT in black ink
A. Section A to be completed by the employer and/or worker.
First Name
Worker's Last Name Telephone
City/Town
Address (no., street, apt.) Province
Postal Code
Employer's Name Date of Birth
(dd/mm/yyyy)
Full Address (No., Street, Apt.)
Date of Accident/
Awareness of Illness
(dd/mm/yyyy)
City/Town
Prov. Postal Code
Employer
Telephone
Employer
Fax No.
fold
Area(s) of injury(ies)/illness(es)
1. Type of job at time of accident (where available, please attach description of job activities)
fold
dd mm yyyy
2. Have the worker and the employer discussed Return To Work
lf no, will be discussed on
yes no
3. Employer contact name Position
B. Worker's Signature
By signing below, I am authorizing any health professional who treats me to provide me, my employer and the Workplace Safety and Insurance Board (WSIB) with
information about my functional abilities on the WSIB's "Functional Abilities for Planning Early and Safe Return to Work" form.
dd mm yyyy
Signature Date
C. Health Professional's Billing Information
For billing purposes fax or mail pages 2 and 3 to the WSIB.
Health Professional's Designation
Chiropractor Physician Physiotherapist Registered Nurse (Extended Class) Other
PROVIDER BILLING INFORMATION IN THE BOLDED AREA OF SECTION C SHOULD NOT BE PROVIDED TO THE WORKER OR EMPLOYER.
WSIB Provider ID.
Are you registered
with the WSIB?
yes Please enter the WSIB Provider ID. in the box provided
no Please call 1 - 800-569-7919 to register
Your Invoice Number
Health Professional's Name (please print)
Service Code
FAF
Complete these fields if HST is applicable to this form
Address (No. Street, Apt.)
HST Registration Number
Service Code
HST Amount Billed
ONHST $ .
Province Postal Code
Fax
City/Town
I hereby declare that the information being submitted in Sections C, D, E and F of this form is true and complete. It is an
offense to knowingly make a false or misleading statement or representation to the WSIB.
dd mm yyyy
Telephone Date
Health Professional's Signature
page 2 of 4
2647A2 (07/06)
Start >
University of Guelph
50 Stone Road E.
Guelph,
ON
N1G 2W1
824-4120
519
780-1796
Heather Sewell
Rehabilitation Specialist
print
reset
Please print form & sign before returning to the WSIB
Please print form & sign before returning to the WSIB
...go to next page
Mail to:
200 Front Street West
Toronto ON M5V 3J1
or Fax to:
416 344-4684
OR 1-888-313-7373
Functional Abilities Form
for Planning Early
and Safe Return to Work
Please PRINT in black ink FAF
Claim No.
First Name
Worker's Last Name
D. The following information should be completed by the Health
Professional to identify the patient's overall abilities and restrictions.
dd mm yyyy
1. Date of
Assessment
2. Please check one:
Patient is capable of
returning to work with
no restrictions.
Patient is capable of returning
to work
with restrictions.
Complete sections E and F.
Patient is physically unable to
return to work at this time.
Complete section
F.
E. Abilities and/or Restrictions
1. Please indicate Abilities that apply. Include 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)
Ladder climbing: Travel to work:
Lifting from waist to shoulder: Stair climbing:
Full abilities Full abilities Full abilities Ability to use
public transit
Ability to
drive a car
Up to 5 kilograms Up to 5 steps 1 - 3 steps
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. Include additional details in section 3
Limited use of hand(s):
Environmental
exposure to: (e.g. heat,
cold, noise or scents)
Work at or above
shoulder activity:
Chemical
exposure to:
Bending/twisting
repetitive movement of
(please specify)
Left
Right
Gripping
Pinching
Other (please specify)
Limited pushing/pulling with:
Operating motorized equipment:
(e.g. forklift)
Potential side effects from
medications (please specify)
Do not include names of
medications.
Exposure to vibration:
Left arm Whole body
Right arm Hand/Arm
Other (please specify)
3. Additional Comments on Abilities and/or Restrictions.
4. From the date of this assessment, the above will apply for approximately: 5. Have you discussed return to work
with your patient?
1 - 2 days 3 - 7 days 8 - 14 days 14 + days yes no
dd mm yyyy
Start Date
6. Recommendations for
work hours and start date:
Regular full-time hours Modified hours Graduated hours
F. Date of Next Appointment
dd mm yyyy
Recommended date of next appointment to review Abilities and/or Restrictions.
I have provided this completed Functional Abilities Form to:
Worker and/or Employer
2647A3 (07/06) page 3 of 4
Start >
...go to next page
reset
print
Important Information
To receive benefits, the worker must apply for benefits within six months of the date of a work-related injury or illness.
When filing a claim for benefits, the worker must also consent to the disclosure of functional abilities information
provided by a health professional to his or her employer for the purpose of facilitating an early and safe return to work.
Failure to file a claim or provide consent for the release of the functional abilities information can result in no benefits.
If you have questions about the completion of this form please call 1-800-387-0750.
Worker's Responsibilities
•
•
This form is to be completed by a treating health professional, who will discuss the information with you.
Once completed, contact your employer immediately to review the information on the completed form. Together, you
and your employer will begin to plan an early and safe return to work.
Employer's Responsibilities
•
•
•
•
•
•
•
This form provides general information about this worker's functional abilities and restrictions to help you plan an
early and safe return to work.
When you provide this form to the treating health professional, ensure that you have the worker's signed consent
(Section B) for the release of functional abilities information.
Where available, also attach a description of the worker's job activities to assist the health professional in completing
the form.
The prescribed form that is available from the WSIB is a generic form developed to assist with general functional abilities
information.
The WSIB will pay the health professional to complete the prescribed WSIB form only. A charge will appear on your
Accident Cost statement or Schedule 2 Invoice which reflects the cost of payment for each form completed.
If you have a form that is specific to your workplace and have the cooperation of the worker in providing consent for the
release of information on your form, you may use your own form. If you create your own form, you must reimburse the
health professional directly.
Do not send a copy of the completed Functional Abilities Form for Planning Early and Safe Return to Work to the WSIB.
The health professional is responsible for submission of the form.
Health Professional's Responsibilities
•
•
•
•
•
•
•
•
The employer and worker will use this information to plan the worker's early and safe return to work.
Their return to work plans will reflect the functional abilities and restrictions you have noted and presume that no clinical
contraindications exist for other work activities, therefore it is crucial that all sections be completed in full.
The completion of this form is based on your examination of the worker and does not require a specialized functional
abilities evaluation.
Diagnostic or confidential information must not be included.
Please add specific information on the duration of temporary restrictions or maximum times or weights to be considered,
in section E3 under abilities and/or restrictions. If necessary, attach an additional page to this completed form to
describe abilities and restrictions.
Completion of this form does not replace clinical reporting requirements to the WSIB.
Once you have received this form, promptly complete it and give it to the worker and/or employer.
For billing purposes fax or mail pages 2 and 3 to the WSIB. When faxing, do not mail a copy.
The WSIB will pay the health professional for the completed form when pages 2 and 3 are received.
WSIB Fax 416-344-4684
or 1-888-313-7373
Workplace Safety and Insurance Board
200 Front Street West
Toronto ON M5V 3J1
revised june 2010
page 4 of 4
2647A4 (07/06)
A guide to completing this form is available at www.wsib.on.ca
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FAF 2647A1 (University of Guelph)

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Completed 22 July 2020

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