Workplace Capabilities Form Return To Work Authorization
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1Workplace Capabilities Form/
Return to Work Authorization
ATTENTION: ATTENDING MEDICAL PRACTITIONER
The University of Manitoba has modified employment available to aid in the early & successful rehabilitation of ill or
injured workers. In order to identify suitable work, we request your assistance by completing this form, which will enable
us to provide the employee with duties within his/her capabilities & your guidelines. Your cooperation is appreciated.
Employee Name:
Date of Assessment:
, 2015
Employee may return to work without restrictions on
_______________________.
Employee is totally disabled. Estimated duration of absence _______ Days ______ Weeks.
Employee may return to modified work with restrictions as below effective ___________________.
complete section ‘A’ for physical injury/illness OR section ‘B’ for non-physical medical conditions
(
)
(A)
(B)
Physical Injury/Illness Restrictions
Non-Physical Capability Assessment
Lifting & Carrying
Please check appropriate boxes to indicate and describe current
abilities. Numbers from 1 to 4 indicate the level of intensity
Avoid lifting above shoulders
1
2
3
4
Abilities
Avoid lifting over ____ lbs from floor to waist
low
high
Avoid lifting over ____ lbs from waist to shoulders
Sustaining concentration
Avoid unilateral carrying over ____ lbs
Screening out environmental stimuli
Avoid bilateral carrying over ____ lbs
Maintaining work stamina/pace
Limbs
Handling time pressures & multiple tasks
Limited reaching, pushing of injured arm
Interacting with the public
Limited grasping, squeezing, carrying of injured hand
Responding to negative or other feedback
Use of opposite hand/arm only
Minimal manual dexterity of injured digit
Dealing with confrontation
Limited repetitive movements of hand/arm/wrist
Working cooperatively with others
Mobility
Managing emotions
Avoid prolonged standing > __________ hours/minutes
Working without supervision
Avoid prolonged sitting > __________ hours/minutes
General Comments/Other Functional Limitations:
Avoid kneeling, squatting or crawling
___________________________________________
Avoid excessive walking.
Avoid repetitive bending or twisting
___________________________________________
Other Restrictions
___________________________________________
Keep wound clean and dry
Must wear splint, brace or sling
___________________________________________
This person should not be exposed to:
Heat
Working at heights
___________________________________________
Cold
Mechanical hazards/moving machinery
Other restrictions not listed above (including reduced hours of work, graduated hours etc.):
___________________________________________________________________
___________________________________________________________________
Estimated duration of above restrictions:
_______ Days ______ Weeks.
Date of Next Appointment: ___________________________
_____________________________
Attending Medical Practitioner Signature
************************************************************************************************************
I authorize my medical practitioner to release the above information about my medical condition to my employer.
____________________________________
______
_________
Employee Signature
Date
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