Abilities Form
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1
2Abilities, Wellness & Attendance
Human Resources Support Services
Tel: 905.890.1010 Ext. 2762 or 2428
Fax: 905.890.0485
ABILITIES FORM
A. The following should be completed by the patient to provide his/her information and consent.
Please select one:
Workplace Injury/Illness
Other (Non-occupational)
Last Name:
First Name:
Address:
Telephone Number:
Date of Birth (dd/mm/yy):
Employee ID:
WSIB Claim #:
(If applicable)
I authorize the health care professional to release the information requested on this Abilities Form to the Peel District
School Board as it relates to my current absence from work or needs for accommodation at work.
________________________________________________
________________________________________
Patient’s Signature
Date (dd/mm/yy)
B. The following should be completed by the Health Practitioner to identify the patient’s overall abilities and restrictions.
Date of Assessment: (dd/mm/yy)
Please check one:
Patient is capable of returning to work with no restrictions.
____________________________
Area of injury/illness:
Patient is capable of returning to work with restrictions. Complete C to F.
Patient is physically/psychologically unable to return to work. Complete C to F.
____________________________
C. Physical Abilities: Please indicate abilities that apply.
Walking:
Standing:
Sitting:
Lifting floor to waist:
Full abilities
Full abilities
Full abilities
Full abilities
Up to 100 meters
Up to 15 minutes
Up to 30 minutes
Up to 5 kilograms
100 - 200 meters
15-30 minutes
30 minutes – 1 hour
5-10 kilograms
Other (specify)
Other (specify)
Other (specify)
Other (specify)
_____________________
_____________________
_____________________
_____________________
Lifting waist to shoulder:
Stair climbing:
Pushing/pulling:
Travel to work:
Full abilities
Full abilities
Full abilities
Ability to drive car
Up to 5 kilograms
Up to 5 steps
Up to 5 kg of force
Yes
No
5-10 kilograms
5-10 steps
Up to 10 kg of force
Other (specify)
Other (specify)
Other (specify)
Ability to use public transit
Yes
No
_____________________
_____________________
_____________________
D. Work Restrictions: Please indicate restrictions that apply.
Bending/twisting repetitive
Work at or above shoulder
Chemical exposure to:
movement of (please specify):
activity:
____________________________
____________________________
____________________________
Environmental exposure to
Operating motorized equipment:
Potential side effects from
(e.g. heat, cold, noise, scents):
medications (do not include names):
____________________________
____________________________
____________________________
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Parent category: Business