Functional Abilities Form
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1Functional Abilities Form
Government
Employee is to provide FAF to supervisor within one business day after obtaining information
For payment, send to: HEALTH, SAFETY and DISABILITY BRANCH, Public Service Commission, Government of Yukon
Fax: 867-456-3977
EMPLOYEE’S INFORMATION
HEALTH CARE PROVIDER’S INFORMATION
Surname: ________________________________________
Health Care Provider’s Name: _______________________
First Name: _______________________________________
__________________________________________________
Male
Telephone #: _________________________
__________________________________________________
Female
Date of Birth: ________________________
__________________________________________________
Date of injury/illness: _______________________________
Health Care Provider’s Address: _____________________
Part of body injured (if applicable): ___________________
__________________________________________________
Supervisor/Department HR Contact
__________________________________________________
Name: ____________________________________________
__________________________________________________
Fax Number: _____________________________________
Health Care Provider’s Telephone #: _________________
OR Health Care Provider’s Stamp: ___________________
__________________________________________________
PART A
__________________________________________________
Patient has no functional limitations
PART B
Due to a medical condition, patient has functional limitations in the following areas. The patient can return to
work providing the following limitations can be appropriately accommodated:
No lifting
Climbing stairs/ladders
Stamina/Fatigue*
No overhead lifting
Standing*
Decision Making*
Lifting as tolerated
Sitting*
Memory*
Walking*
Limitations due to medication*
Reduced hours*
Use of upper extremity*
Limitations due to environmental conditions*
Concentration*
Bending, twisting or kneeling
Problem solving*
Other*: _____________________________________________________________________________________
* Please provide further details of these limitations: ____________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Estimated duration of functional limitations (in days): _________________________________________________________
I have reviewed details of this report with patient
Date of visit: _______________________
I certify that this is a complete and accurate report. The fees charged are in accordance with the medical fee
schedule and I have received no prior payment.
Health Care Provider’s Signature: _______________________________________ Date of next visit: __________________
YG(5954Q)F1 Rev.04/2014
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