Employee Name:	Current Position:
Type of Disability: (circle one)	Physical Complete Sections A, C, D, E	Mental Complete Sections B, C, D, E

Diagnosis:	Disability is (circle one):	Permanent Temporary
If Temporary estimated length of disability:

Please indicate the level of work that is within this employee’s physical and mental capabilities.

Section A	Physical Capacities
1. Job Classification - General
Sedentary Work Light Work Medium Work Heavy Work Very Heavy Work	Lifting 10 pounds maximum Lifting 25 pounds maximum Lifting 50 pounds maximum Lifting 100 pounds maximum Lifting over 100 pounds
2. Physical Requirements
Key	Never:	Not at all
Rarely:	Occurring during less than 5% of the workday
Occasionally:	6-20% of the workday
Frequently:	21-50% of the workday
Continuously:	51% or more of the workday

Never	Rarely	Occasionally	Frequently	Continuously
Sit	_____	_____	_____	_____	_____
Stand	_____	_____	_____	_____	_____
Walk	_____	_____	_____	_____	_____
Bend	_____	_____	_____	_____	_____
Crawl	_____	_____	_____	_____	_____
Kneel	_____	_____	_____	_____	_____
Squat	_____	_____	_____	_____	_____
Reach Forward	_____	_____	_____	_____	_____
Twist	_____	_____	_____	_____	_____

Lifting:

Never	Rarely	Occasionally	Frequently	Continuously
0-10 lbs	_____	_____	_____	_____	_____
11-25 lbs	_____	_____	_____	_____	_____
26-50 lbs	_____	_____	_____	_____	_____
51-100 lbs	_____	_____	_____	_____	_____
100+ lbs	_____	_____	_____	_____	_____

Carrying:

Never	Rarely	Occasionally	Frequently	Continuously
0-10 lbs	_____	_____	_____	_____	_____
11-25 lbs	_____	_____	_____	_____	_____
26-50 lbs	_____	_____	_____	_____	_____
51-100 lbs	_____	_____	_____	_____	_____
100+ lbs	_____	_____	_____	_____	_____

Manipulation:

Right	Left
Simple Grasping	_____ Yes	_____ No	_____ Yes	_____ No
Fine Manipulation	_____ Yes	_____ No	_____ Yes	_____ No
Pushing and Pulling	_____ Yes	_____ No	_____ Yes	_____ No
Repetitive Foot Motions	_____ Yes	_____ No	_____ Yes	_____ No

Section B	Mental Capacities
Evaluate each mental activity within the context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis.

Not Limited	Moderately Limited	Markedly Limited
Ability to remember locations and work-like procedures	_____	_____	_____
Ability to understand and remember short simple instructions	_____	_____	_____
Ability to understand and remember detailed instructions	_____	_____	_____
Ability carry out short and simple instructions	_____	_____	_____
Ability to carry out detailed instructions	_____	_____	_____
Ability to maintain attention and concentration for extended periods	_____	_____	_____
Ability to perform activities within a schedule, maintain regular attendance, punctuality	_____	_____	_____
Ability to sustain an ordinary routine without special supervision	_____	_____	_____

Ability to work in conditions with or in proximity to others without being distracted	_____	_____	_____
Ability to make simple work-related decisions	_____	_____	_____
Ability to complete a normal workday and workweek without interruptions from physiologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods	_____	_____	_____
Ability to interact appropriately with the general public	_____	_____	_____
Ability to ask simple questions or request assistance	_____	_____	_____
Ability to accept instructions and respond appropriately to criticism from supervisors	_____	_____	_____
Ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes	_____	_____	_____
Ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness	_____	_____	_____
Ability to respond appropriately to changes in the work setting	_____	_____	_____
Ability to be aware of normal hazards and take appropriate precautions	_____	_____	_____
Ability to travel to unfamiliar places or use public transportation	_____	_____	_____
Ability to set realistic goals or make plans independently of others	_____	_____	_____

Section C	Comments

Section D	Name and Address of Physician completing this form

Physician Signature: _________________________________________	Date: _____________