Form Medco-14 - August 2015 Physicians Report Of Work Ability Page 3
Download a blank fillable Form Medco-14 - August 2015 Physicians Report Of Work Ability in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Medco-14 - August 2015 Physicians Report Of Work Ability with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Print or Fax
Physician’s Report of Work Ability
Injured worker name
Claim number
Date of injury
Date of last appointment/examination Date of this appointment/examination Date of next appointment/examination
MEDCO-14 submission
(Select one of the options below.)
I have never completed a MEDCO-14.
Proceed to section 2.
1
I have previously completed a MEDCO-14, and all of the information remains the same.
Proceed to and complete section 8.
I have previously completed a MEDCO-14, and I am providing updates appropriately checking Yes or No on each section.
Employment/Occupation (
Complete this section and proceed to section 3.)
(Updates Yes
No
)
Have you reviewed the description of the injured worker’s job held on the date of injury (former position of employment)? Yes
No
2
If yes - please indicate who (select all sources) provided the job description
Injured worker
Employer
MCO
BWC
Work status/Injured worker’s capabilities
(Updates Yes
No
)
Does the injured worker have any physical or health restrictions related to allowed conditions in the claim? Yes
No
3A
If yes, are the restrictions:
Permanent
Temporary
Proceed to section 3B.
If no, please check the box to indicate the injured worker is released to work as of the date of this exam.
Proceed to section 8.
If there are restrictions, can the injured worker return to the full duties of his/her job held on the date of injury (former position of
employment)? Yes
No
If yes, please check the box to indicate that the injured worker is released to work as of the date of this exam.
Proceed to section 8.
If no, please indicate when the injured worker could not do the job held on the date of injury for this period of restricted duty.
3B
Date:_______________.
Please estimate when the injured worker should be able to return to the job held on the date of injury for this period of restricted duty.
Date:_______________.
Proceed to section 3C.
Please indicate which of the activities listed below the injured worker can perform (even if the response to 3B is No.)
If the injured worker is not released to the former position of employment but may return to available and appropriate work with
restrictions, please indicate the possible return to work date:______________.
The injured worker can perform simple grasping with:
Left hand
Right hand
Both
The injured worker can perform repetitive wrist motion with:
Left hand
Right hand
Both
The injured worker’s dominant hand is:
Left
Right
The injured worker can perform repetitive actions to operate foot controls or motor vehicles with:
Left foot
Right foot
Both
If the injured worker is taking prescribed medications for the allowed conditions in this claim, can the injured worker safely:
*Operate heavy machinery:
Yes
No *Drive:
Yes
No *Perform other critical job tasks as defined by any source listed
above in section 2:
Yes
No
Please indicate the following: N = Never, O = Occasionally, F = Frequently, C = Continuously
Lifting/carrying
N
O
F
C
Pushing/pulling
N
O
F
C
Activity
Activity
N
O
F
C
0 - 10 lbs.
0 to 25 lbs.
N
O
F
C
Bend
Reach above shoulder
11 - 20 lbs.
26 to 40 lbs.
Squat/kneel
Type/keyboard
21 - 40 lbs.
41 to 60 lbs.
Twist/turn
Work with cold substances
41 - 60 lbs.
61 to 100 lbs.
3C
Climb
Work with hot substances
61 - 100 lbs.
100 + lbs.
How many total hours can the injured worker work: _____ per week _____ per day?
In an eight-hour workday, how many total hours can the injured worker: Sit: ____ hours
Continuously
With break
Walk: ____ hours
Continuously
With break Stand: ____ hours
Continuously
With break
Does the injured worker have any functional restrictions based only on allowed psychological conditions?
Yes
No If Yes,
please describe in space provided below. Note: If Yes is indicated please reference the MEDCO-16 as needed.
Additionally, in this space, please provide any additional information addressing the injured worker’s capabilities and/or job
accommodations which may not be addressed above.
Proceed to section 4.
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Oic-wc-1 - Employees' And Physicians' Report Of Occupational Injury Or Disease - West Virginia Workers' Compensation
Legal
Form Nyc-115 - Unincorporated Business Tax Report Of Change In Taxable Income Made By Internal Revenue Service - 2015
Financial
Related Categories
Parent category: Business