BUREAU OF STATE RISK MANAGEMENT DIVISION OF ENTERPRISE OPERATIONS STATE OF WISCONSIN DEPARTMENT OF ADMINISTRATION DOA-6041 (R05/2007) Estimated Functional Capacities Name State Agency Please complete the following items based on your estimated clinical evaluation. If you have any questions regarding this form please call: Name 1. Telephone Number In an 8 hour workday (Includes a 15 min. break/4 hours; and ½ hour lunch/8hour work shift.) the patient/employee can: (indicate full capacity for each activity) N/A 1 Hr 2 Hrs 3 Hrs 4 Hrs 5 Hrs 6 Hrs 7 Hrs 8 Hrs Never Continuously Sit Stand Walk 2. 3. Indicate the capacity in which the patient/employee can do each of the following activities. N/A Never Continuously N/A Lift 10 lbs Bend 11-20 lbs Squat 21-50 lbs Crawl 51-100 lbs Climb Carry 10 lbs Reach Above 11-20 lbs Shoulder Level 21-50 lbs 51-100 lbs Patient/employee can use hands for repetitive actions such as: Simple Grasping N/A Yes No Right Left Pushing & Pulling Yes No 4. Continuously Fine Manipulating Yes No Patient/employee can use feet for repetitive movements as in operating foot controls: N/A Yes No Right Left Both 5. Never Restriction of activities involving: N/A None Mild Moderate Total Unprotected Heights Being Around Moving Machinery Exposure to Marked Changes in Temperature & Humidity Operation of Motor Vehicles Operation of Industrial Equipment Operation of Heavy Custodial Equipment 1. Auto-scrubber 2. Single-disc floor machine - 20” 3. Carpet Extractor 4. 14” Vacuum Cleaner Exposure to Dust, Fumes, Gases and Cleaning Chemicals Can patient now work? Yes No Full-time Physician’s Signature Part-time (4 hrs/day) Date (mm/dd/ccyy) Please Attach Additional Comments American LegalNet, Inc. www.FormsWorkflow.com