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Doctors Estimate Of Physical Capacities Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Doctors Estimate Of Physical Capacities, F242-022-000, Washington Workers Comp, Claims
DOCTOR'S ESTIMATE OF
PHYSICAL CAPACITIES
Department of Labor and Industries
Claims Section
PO Box 44291
Olympia WA 98504-4291
Name of Claimant
Claim Number
Important: Please complete the following items based on your clinical evaluation of the claimant and other testing
results. Any item that you do not believe you can answer should be marked N/A. Percentages refer to a workday.
I. In an 8 hour workday, worker can: (Circle full capacity for each activity)
Total at one time (hours)
Sit
0 1/2 1 2
Stand
0 1/2 1 2
Walk
0 1/2 1 2
A)
B)
C)
Total during entire 8 hour day (hours)
3
3
3
4
4
4
5
5
5
7
7
7
A)
B)
C)
8
8
8
Sit
Stand
Walk
0
0
0
1/2
1/2
1/2
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
(Address any restrictions in lifting from the floor or to overhead in “Remarks” section)
II. Worker can lift:
III. Worker can carry:
Not at all
Seldom
(1 - 10%)
Occasionally
(11 - 33%)
Frequently
(34 - 66%)
Continuously
(67 - 100%)
Lift Carry
Lift Carry
Lift Carry
Lift Carry
Lift Carry
A)
B)
C)
D)
E)
F)
6
6
6
Up to 5 lbs
6 - 10 lbs
11 - 20 lbs
21 - 25 lbs
26 - 50 lbs
51 - 100 lbs
IV. Worker can use hands for repetitive tasks such as:
Simple grasping
A) Right
B) Left
Yes
Yes
Pushing & pulling
Fine manipulating
Yes
Yes
No
No
Yes
Yes
No
No
No
No
V. Worker can use feet for repetitive movements as in operating foot controls:
Right
Yes
No
Not at all
VI. Worker is able to:
A) Bend
B) Squat
C) Kneel
D) Crawl
E) Climb
F) Reach above
shoulder level
Left
Seldom
(1-10%)
Yes
Occasionally
(11 - 33%)
VII. Restriction on activities involving:
Yes No
No
Frequently
(34 - 66%)
Continuously
(67 - 100%)
If “Yes,” explain:
A) Unprotected heights
B) Being around moving machinery
C) Exposure to marked changes in temp & humidity
D) Driving automotive equipment
E) Exposure to dust, fumes and gasses (Restrictions):
Remarks (on above, on other functional limitations):
If a performance-based physical capabilities evaluation is requested, may the worker be tested to tolerance? If not, what are the restrictions?
Yes
No
Date
Signature of Physician
F242-022-000 Dr's est of physical capacities 06-2006
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