Functional Abilities Form - Wsib Page 3
Download a blank fillable Functional Abilities Form - Wsib 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 Functional Abilities Form - Wsib 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
4Mail to:
or Fax to:
Functional Abilities Form
FAF
200 Front Street West
416 344-4684
for Planning Early
Toronto ON M5V 3J1
OR 1-888-313-7373
and Safe Return to Work
Please PRINT in black ink
Worker's Last Name
First Name
Claim No.
D. The following information should be completed by the Health
Professional to identify the patient's overall abilities and restrictions.
1. Date of
dd
mm
yyyy
2. Please check one:
Assessment
Patient is capable of
Patient is capable of returning
Patient is physically unable to
returning to work with
with restrictions
to work
.
return to work at this time.
no restrictions.
E and F.
F.
Complete sections
Complete section
Start >
E. Abilities and/or Restrictions
1. Please indicate Abilities that apply. Include additional details in section 3
Walking:
Standing:
Sitting:
Lifting from floor to waist:
Full abilities
Full abilities
Full abilities
Full abilities
Up to 100 metres
Up to 15 minutes
Up to 30 minutes
Up to 5 kilograms
100 - 200 metres
15 - 30 minutes
30 minutes - 1 hour
5 - 10 kilograms
Other (please specify)
Other (please specify)
Other (please specify)
Other (please specify)
Ladder climbing:
Travel to work:
Lifting from waist to shoulder:
Stair climbing:
Full abilities
Full abilities
Full abilities
Ability to use
Ability to
public transit
drive a car
Up to 5 kilograms
Up to 5 steps
1 - 3 steps
5 - 10 kilograms
5 - 10 steps
4 - 6 steps
yes
yes
Other (please specify)
Other (please specify)
Other (please specify)
no
no
2. Please indicate Restrictions that apply. Include additional details in section 3
Limited use of hand(s):
Environmental
Work at or above
Chemical
Bending/twisting
Left
Right
exposure to: (e.g. heat,
shoulder activity:
exposure to:
repetitive movement of
Gripping
cold, noise or scents)
(please specify)
Pinching
Other (please specify)
Limited pushing/pulling with:
Operating motorized equipment:
Potential side effects from
Exposure to vibration:
(e.g. forklift)
medications (please specify)
Left arm
Whole body
Do not include names of
Right arm
Hand/Arm
medications.
Other (please specify)
3. Additional Comments on Abilities and/or Restrictions.
4. From the date of this assessment, the above will apply for approximately:
5. Have you discussed return to work
with your patient?
1 - 2 days
3 - 7 days
8 - 14 days
14 + days
yes
no
Start Date
6. Recommendations for
dd
mm
yyyy
Regular full-time hours
Modified hours
Graduated hours
work hours and start date:
F. Date of Next Appointment
dd
mm
yyyy
Recommended date of next appointment to review Abilities and/or Restrictions.
I have provided this completed Functional Abilities Form to:
Worker
and/or
Employer
2647A3 (07/06)
page 3 of 4
...go to next page
reset
print
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal