Employee's Name (please print): Date of Birth:
Date of Assessment:
Yes No
Reason for Absence/Modifications:
Treatment: No
Treatment Plan (including medications):
Summarize Response to Treatment:
Barriers for Return to Work:
Complete Recovery Expected? Yes
Estimated Return to Work Date (if currently absent):
Fit (full hours & duties)
Unfit Fit with Precautions
Modified Hours (please specify):
Current Functional Limitations:
Estimated Duration of Limitations: Permanent
Function
Walk Continuously Limit to Minutes Hours
Stand Continuously Limit to Minutes Hours
Sit Continuously Limit to Minutes Hours
Grip Pinch Limit to
Push/Pull Limit to Kg
Bend/Twist (of: ) Frequency
Limit to Kg
Limit to Kg
Limit to Kg
Climb: Ladder Stairs Limit to
Restricted Use of Limbs? Specify:
Understanding/Memory
Attention to Detail/Concentration
Need to work co-operatively with others
Adaptation/Ability to Accommodate Change
Responsibility/Accountability/Decision-making
Communication/Comprehension
Performance of Multiple Tasks
Ability to Work to Deadlines
Exposure to Environmental Stimuli/Distraction
Stamina/Energy
Operation of Motorized Equipment
Other:
(Treating Practitioner's Name - Please Print) (Signature) (Date)
Rehabilitation Services will reimburse the treating practitioner for full completion of this form.
Western University Support Services Building Room 4159 London ON N6A 3K7 519-661-2111 Fax 519-661-2079 · E-mail: rehab@uwo.ca
PART II - May be copied to individuals who are assisting with accommodation process
PART I - Information will not be released by Rehabilitation Services without signed authorization
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
Mild Moderate Severe
FUNCTIONAL ACCOMMODATION FORM
Rehabilitation Required? Yes
Level of Limitation
Is the claim being submitted to the
Workplace Safety & Insurance Board?
No Unknown
Date of Next Medical Review:
Comments
Comments
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