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

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1600 E
EAST CENTURY
Y AVENUE, SUIT
TE 1
C
APABILITY
Y ASSESS
SMENT
PO BOX 55
585
CL
LAIMS DIVIS
SION
BISMAR
RCK ND 58506-55
585
SF
FN 58550 (04/20
012)
Telepho
one 1-800-777-50
033
Toll Free F
Fax 1-888-786-86
695
TTY
Y (hearing impaire
ed) 1-800-366-68
888
Fraud
and Safety Hotl
ine 1-800-243-33
331
WorkforceSafety.c
com
PLE
EASE TYPE OR
R PRINT USING
BLACK OR BLU
UE INK. SEE RE
EVERSE FOR A
ADDITIONAL INS
STRUCTIONS.
Claim Numbe
er
Injury D
Date
Birth Date
Soci
al Security Num
ber
Injured Worke
er’s Name
Employ
yer’s Name
Emp
ployer’s Phone N
umber
Injured Worke
er’s Address
Injur
red Worker’s Pho
one Number
Diagnosis C
ode/ICD9 Code
Visit Date
Part of Bo
ody Injured
Purpose:
Initial Evaluation
n
Re-check
k
Discharge
If this is the
initial evaluatio
on, please comp
plete the next qu
uestion.
Any reported
pre-existing/ass
ociated condition
ns?
Yes
No
Injured worke
er is released to w
work with:
N
No restrictions
With the follo
owing restrictions
s (If so, please c
complete below)
Restrictions a
are in effect until_
______________
______________
__
Restrictions o
ordered are in effe
ct for home and/o
or work activity.
Physic
cal Capabilitie
es
Not
Seldom
Occas
sional
F
Frequent
Constant
(Related
d to work injury
y):
Rec
ommended
1-5%
6-33
3%
34-66%
67-100%
Sit
Stand / Walk
Climb (ladder
rs/stairs)
Twist
Bend / Stoop
Squat / Knee
l
Crawl
Reach (Left,
Right, Both)
Work above s
shoulders (L, R,
B)
Wrist (L, R, B
B)
Grasp (L, R,
B)
Fine Manipula
ation (L, R, B)
Operate foot
controls (L, R, B
B)
Drive / Opera
ate Machinery
Lifting/Push
ing
Not
Recommended
d
Seldo
om
Occasional
Freq
quent
Constant
Lift (L, R, B)
lbs
lbs
lbs
lbs
lbs
Carry (L, R, B
B)
lbs
lbs
lbs
lbs
lbs
Push / Pull
lbs
lbs
lbs
lbs
lbs
Other instruc
ctions and/or lim
mitations:
Restrictions b
based upon:
Workability
Functional
Capacity Assess
sment
P
Physical Exam
Follow-up P
lan
Next visit
with this provide
r:____________
_______
Med
dication Prescrib
bed:___________
______________
___
Referral to
o:____________
____________
Oth
her:___________
______________
________
Consult w
with:___________
______________
______
H
as injured w
worker reached m
maximum medica
al improvement (
(MMI)?
Yes
No
D
ate___________
_______
If yes, is it like
ely that the perm
manent partial imp
pairment (PPI) w
will be greater tha
an 14% whole bo
ody?
Yes
No
Unknow
wn
FRAU
UD WARNING
By signing this
form, I acknowledg
ge that I have read
the Fraud Warning
g on the reverse sid
de of this form and
understand that fa
alsifying this claim o
or
making
g a false statement
regarding this claim
m may be a felony
punishable by sub
stantial fines and im
mprisonment. By m
my signature below
w, I declare that the
e statements on this
s
form ar
re true and accurat
te.
Physic
cian’s Signature
F
Facility
Federal Tax
x ID
Phone Nu
umber
I authorize the
release of this report
and any other medica
al
Injured
d Worker’s Signa
ature
Date
C3
information rela
ated to my claim to my
y employer, Workforce
e
Safety & Insura
ance (WSI) and its age
ents.
Please com
mplete sign, an
d return this for
rm to WSI imme
ediately. Promp
pt payment of c
ompensation d
epends on this
form.

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