Abilities Form (Page 2 of 2) in pdf

D. Work Restrictions (continued): Please indicate restrictions that apply.

Stooping

Squatting

Kneeling

____________________________

___________________________

____________________________

E. Cognitive Abilities: Please indicate abilities that apply.

Memory/concentration:

Following directions:

Making decisions:

Full abilities

Limited abilities (specify)

____________________________

Multi-tasking:

Working with others:

Working alone:

Full abilities

Limited abilities (specify)

____________________________

F. Additional information:

Has a referral to a specialist been made?

Yes

Not Applicable

Referral date: ____________________________ Specialist’s name: _____________________________________

Is patient on an active treatment plan?

Yes

If yes, please indicate frequency___________________________________________________________________

From the date of this assessment, the above will apply for approximately:

Have you discussed return to work with

your patient?

1 week

2 weeks

3 weeks

4 weeks

Other: _____________

Yes

Recommendations for work hours and start date:

Assistive devices required:

Regular full time hours

Modified hours

Graduated hours

Yes

Specify: ___________________________________________________

Specify: ________________________

Start date (dd/mm/yy): ________________________________________

______________________________

Date of next appointment (dd/mm/yy):

Health Care Professional’s signature:

Date completed (dd/mm/yy):

Health Care Professional’s name and contact information:

WSIB Provider ID:

(If applicable)

Note: The patient is responsible for the cost of completing the initial Abilities Form, except for WSIB claims. The Peel District

School Board will assume reasonable and customary payment in all other circumstances.

Revised 07/12

Page 2 of 2

Abilities Form Page 2

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