Form Sfn 58550 - Capability Assessment - North Dakota Workforce Safety & Insurance

1600 EAST CENTURY AVENUE, SUITE 1

CAPABILITY ASSESSMENT

PO BOX 5585

CLAIMS DIVISION

BISMARCK ND 58506-5585

SFN 58550 (05/2008)

Telephone 1-800-777-5033

Toll Free Fax 1-888-786-8695

TTY (hearing impaired) 1-800-366-6888

Fraud and Safety Hotline 1-800-243-3331

PLEASE TYPE OR PRINT USING BLACK OR BLUE INK. SEE REVERSE FOR ADDITIONAL INSTRUCTIONS.

Claim Number

Injury Date

Birth Date

Social Security Number

Injured Worker’s Name

Employer’s Name

Employer’s Phone Number

Injured Worker’s Address

Injured Worker’s Phone Number

Diagnosis Code/ICD9 Code

Visit Date

Part of Body Injured

Purpose:

Initial Evaluation

Re-check

Discharge

If this is the initial evaluation, please complete the next question.

Any reported pre-existing/associated conditions?

Yes

No

Injured worker is released to work with:

No restrictions

With the following restrictions (If so, please complete below)

Restrictions are in effect until___________________________

Restrictions ordered are in effect for home and/or work activity.

Physical Capabilities

Not

Seldom

Occasional

Frequent

Constant

(Related to work injury):

Recommended

1-5%

6-33%

34-66%

67-100%

Sit

Stand / Walk

Climb (ladders/stairs)

Twist

Bend / Stoop

Squat / Kneel

Crawl

Reach (Left, Right, Both)

Work above shoulders (L, R, B)

Wrist (L, R, B)

Grasp (L, R, B)

Fine Manipulation (L, R, B)

Operate foot controls (L, R, B)

Drive / Operate Machinery

Lifting/Pushing

Not Recommended

Seldom

Occasional

Frequent

Constant

Lift (L, R, B)

lbs

lbs

lbs

lbs

lbs

Carry (L, R, B)

lbs

lbs

lbs

lbs

lbs

Push / Pull

lbs

lbs

lbs

lbs

lbs

Other instructions and/or limitations:

Restrictions based upon:

Workability

Functional Capacity Assessment

Physical Exam

Follow-up Plan

Next visit with this provider:__________________

Medication Prescribed:_________________________

Referral to:_______________________

Other:_______________________________

Consult with:_____________________________

H

as injured worker reached maximum medical improvement (MMI)?

Yes

No

Date_________________

If yes, is it likely that the permanent partial impairment (PPI) will be greater than 16% whole body?

Yes

No

Unknown

–

FRAUD WARNING

By signing this form, I acknowledge that I have read the Fraud Warning on the reverse side of this form and understand that falsifying this claim or

making a false statement regarding this claim may be a felony punishable by substantial fines and imprisonment. By my signature below, I declare that the statements on this

form are true and accurate.

Physician’s Signature

Facility

Federal Tax ID

Phone Number

I authorize the release of this report and any other medical

Injured Worker’s Signature

Date

C3

information related to my claim to my employer, Workforce

Safety & Insurance (WSI) and its agents.

Please complete sign, and return this form to WSI immediately. Prompt payment of compensation depends on this form.