Form Medco-14 - July 2015 Physicians Report Of Work Ability Page 2
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2
3Physician’s Report of Work Ability
Injured worker name
Claim number
Date of injury
Date of last appointment/examination
Date of this appointment/examination
Date of next appointment/examination
MEDCO-14 submission
(Select one of the options below.)
I have never completed a MEDCO-14. Proceed to section 2.
1
I have previously completed a MEDCO-14, and all of the information remains the same.
Proceed to and complete section 8.
I have previously completed a MEDCO-14, and I am providing updates to each section checked.
Employment/Occupation
(Updates Yes
No
)
Complete this section and proceed to section 3
Have you reviewed the description of the injured worker’s job held on the date of injury (former position of employment)? Yes
No
2
If yes - please indicate who (select all sources) provided the job description
Injured worker
Employer
MCO
BWC
Work status/Injured worker’s capabilities
(Updates Yes
No
)
Does the injured worker have any work restrictions related to allowed conditions in the claim? Yes
No
3A
If yes, proceed to section 3B.
If no restrictions, please indicate release to work date ______/______/______.
Proceed to and complete sections 6 and 8.
If there are work restrictions, can the injured worker return to his/her job held on the date of injury (former position of
employment)? Yes
No
If yes, please indicate release to work date: _____/_____/_____.
Proceed to sections 3C, 5, 6, and 8.
3B
If no, please indicate when the injured worker initially could not do the job held on the date of injury. Date:_____/_____/_____.
Please estimate when the injured worker should be able to return to the job held on the date of injury for this period of restricted duty.
Date:_____/_____/_____.
Proceed to section 3C.
Please indicate which of the activities listed below the injured worker can perform (even if the response to 3B is “no”.)
The injured worker can perform simple grasping with: Left hand
Right hand
Both
The injured worker can perform repetitive wrist motion with: Left hand
Right hand
Both
The injured worker’s dominant hand is:
Left
Right
The injured worker can perform repetitive actions to operate foot controls or motor vehicles with: Left foot
Right foot
Both If the
injured worker is taking prescribed medications for the allowed conditions in this claim, is the injured worker able to safely:
*Operate heavy machinery:
Yes
No *Drive:
Yes
No *Perform other critical job tasks as defined by any source listed
above in section 2:
Yes
No
Please indicate the following: N = Never, O = Occasionally, F = Frequently, C = Continuously
Lifting/carrying
N
O
F
C Pushing/pulling
N
O
F
C
Activity
N
O
F
C Activity
N
O
F
C 0 - 10 lbs.
0 to 25 lbs.
Bend
Reach above shoulder
11 - 20 lbs.
26 to 40 lbs.
Squat/kneel
Type/keyboard
21 - 40 lbs.
41 to 60 lbs.
Twist/turn
Work with cold substances
41 - 60 lbs.
61 to 100 lbs.
Climb
Work with hot substances
61 - 100 lbs.
100 + lbs.
3C
In an eight-hour workday, how many total hours is the injured worker able to:
Sit: ____ hours
Continuously
With break
Walk: ____ hours
Continuously
With break
Stand: ____ hours
Continuously
With break
In the space below please provide any additional information addressing the injured worker’s capabilities and/or job accommodations
which may not be addressed above. _____________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Proceed to section 4.
BWC-3914 (Rev. June 30, 2015)
MEDCO-14
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