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Functional Capacity Form
Occupational Health & Wellness
Phone: 519-824-4120 ext. 52647 Fax: 519-780-1796 E-Mail: ohw@uoguelph.ca
The University is committed to making every reasonable effort to assist ill or injured employees in their return to work. The University is also responsible
in meeting its legal requirements for accommodations and making every reasonable effort to accommodate its employees. Please provide the following
information to assist us in planning for your patient’s safe return to work.
Section A: Employee Information (to be completed by employee)
NAME: (Surname)
(Given Names)
Date of Birth (DD/MM/YYYY)
HOME ADDRESS: (Street, City, Postal Code) H
PHONE NO. MANAGER/SUPERVISOR NAME
DEPARTMENT FACULTY/SCHOOL/SERVICE
OME/CONTACT PHONE NO.
JOB TITLE
Section B: Medical Information (to be completed by a qualified health care treatment provider)
Please be advised that by completing this form you are certifying that the information is true and accurate and is in keeping with
professional standards outlined by the professional and regulatory bodies that govern your practice. Please fully complete the following
boxes as appropriate to identify your patient’s capabilities/limitations to ensure the employer can determine the employee’s
accommodation.
Employee fit for full duties Effective Date: ______________________________________
Employee fit for modified duties (See Functional Abilities below). Effective Date:
_______________________
Employee fit modified hours - specify:
_________________________________________________________
Duration:
________________________________
Reassessment Date:
____________________________________
Please identify your patient’s current capabilities/limitations:
Capabilities:
Walking:
full abilities up to 100 m
100-200m
other
_______________
Standing:
full abilities Up to 15 mins
15-30 mins
other
_______________
Sitting:
full abilities Up to 30 mins
30mins 1 hr
other
_______________
Lifting floor to waist:
full abilities Up to 5 kgs
5 10 kgs
other
_______________
Lifting waist to shoulder
full abilities Up to 5 kgs
5 10kgs
other
_______________
Stair climbing:
full abilities Up to 5 steps
5 10 steps
own pace
a
s tolerated
Ladder climbing:
full abilities 1 3 steps
4 6 steps own pace
a
s tolerated
Hand use (R/L):
gripping pinching
fine motor other
_______________
Limitations: Please indicate restrictions that apply.
B
ending/twisting repetitive
movement of (please specify)
Work at or above
shoulder activity:
Chemical Exposure
to:
Environmental exposure to:
(e.g. heat, cold, noise or scents)
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NAME: (Surname
) (
Given Names)
Date of Birth (DD/MM/YYYY)
Limitations: Please indicate restrictions that apply.
Limited pushing/pulling with:
Left Arm
Right Arm
Other (please specify)
_______________________________________________________________________________________________
Operating motorized
equipment: (e.g. forklift)
P
otential side effects from
medications (please specify)
Do not include names of medications.
Exposure to vibration:
Whole body
Hand/Arm
Other
Cognitive Functional Limitations (if applicable): Please indicate the cognitive limitations and associated severity.
Function
Degree of
Impairment
None
Degree of
Impairment
Mild
Degree of
Impairment
Moderate
Degree of
Impairment
Severe
Multi-tasking
Memory
Attend to deadline pressures
Critical decision making
Working with others
Dealing with confrontation
Dealing with emotional situations
Other:
____________________________________
By affixing my signature below, I certify that I am a qualified healthcare provider and that I have personally assessed and treated the
above patient/employee. It is my opinion that the information is true and accurate.
TREATMENT PROVIDER NAME: (Please Print) _ TELEPHONE: ___________________ _________________________________
ADDRESS: _ FAX: _________________________ ______________________________________________________________
SIGNATURE: _____________________________________________________________ DATE: _______________________
Once competed please return by email or fax to Occupational Health and Wellness
at ohw@uoguelph.ca or (519) 780-1796.
Any costs associated with providing the above information will be the responsibility of the employee.
click to sign
signature
click to edit
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