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 1. Ability to remember locations and work-like procedures _____ _____ _____ 2. Ability to understand and remember short simple instructions _____ _____ _____ 3. Ability to understand and remember detailed instructions _____ _____ _____ 4. Ability carry out short and simple instructions _____ _____ _____ 5. Ability to carry out detailed instructions _____ _____ _____ 6. Ability to maintain attention and concentration for extended periods _____ _____ _____ 7. Ability to perform activities within a schedule, maintain regular attendance, punctuality _____ _____ _____ 8. Ability to sustain an ordinary routine without special supervision _____ _____ _____ 9. Ability to work in conditions with or in proximity to others without being distracted _____ _____ _____ 10. Ability to make simple work-related decisions _____ _____ _____ 11. 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 _____ _____ _____ 12. Ability to interact appropriately with the general public _____ _____ _____ 13. Ability to ask simple questions or request assistance _____ _____ _____ 14. Ability to accept instructions and respond appropriately to criticism from supervisors _____ _____ _____ 15. Ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes _____ _____ _____ 16. Ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness _____ _____ _____ 17. Ability to respond appropriately to changes in the work setting _____ _____ _____ 18. Ability to be aware of normal hazards and take appropriate precautions _____ _____ _____ 19. Ability to travel to unfamiliar places or use public transportation _____ _____ _____ 20. 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: _____________ 8005.3 JCS, Inc. Work Capacities Form Page of 4