CAPABILITY ASSESSMENT CLAIMS DIVISION SFN 58550 ( 07/ 201 9 ) 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY (hearing impaired) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www.workforcesafety.com Please type or print using black or blue ink. Return the completed and signed form to WSI immediately. SECTION 1 General information - c ompletion of this section is required Claim number Employee (First name) (Last name) Social Security number* Date of birth Employee (Street address, PO Box number) City State ZIP Code Employee Date of injury SECTION 2 Medical assessment Diagnosis code/ICD - 10 code Date of visit Body part(s) injured Purpose of visit Initial evaluation Re - check Discharge Before this injury, did the employee have any problems, injuries, or treatment to the injured body part? Yes No Injured employee is released to work with No restrictions T he restrictions indicated in S ection 3 SECTION 3 capabilities restrictions ordered are in effect for home and/or work activity Physical capabilities (Related to work injury) Not Recommended Seldom 1 - 5% Occasional 6 - 33% Frequent 34 - 66% Constant 67 - 100% Sit Stand/Walk Climb (Ladders/ S tairs) Twist Bend/Stoop Squat/Kneel Crawl Reach ( L eft, R ight, B oth) Work above shoulders ( L, R, B) Wrist ( L, R, B) Grasp ( L, R, B) Fine manipulation ( L, R, B) Operate foot controls ( L, R, B) Lifting/Pushing Not R ecommended S eldom Occasional Frequent Constant Lift ( L, R, B) lbs lbs lbs lbs lbs Carry ( L, R, B) lbs lbs lbs lbs lbs Push/Pull lbs lbs lbs lbs lbs Restrictions are in effect until Other instructions and/or limitations Restrictions based upon Workability Functional capacity assessment Physical exam SECTION 4 Follow - up plan Next visit with this provider Consult/referral Medication prescribed Has function increased due to opioid therapy? Yes No SECTION 5 Maximum medical improvement (MMI) Permanent partial impairment (PPI) Is recovery compl ete? Yes No Has the injured employee reached MMI? Yes No Date If yes, is it likely that the PPI will be greater than 14% whole body? Yes No Unknown SECTION 6 Release of information/fraud warning/signature By signing this form I acknowledge that I have read the fraud warning and release of information on the reverse side of this form. I understand that falsifying this claim or making a false statem ent regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize the release of information and agree that statements in this form are true and accurate. Facility Telephone number Injured employee Date signed C3 * In compliance with the Federal Privacy Act of 1974, disclosure of the Social Security number on this form is mandatory purs uant to N.D.C.C. 247 65 - 05 - 02. The Social Security number is used for identification and verification purposes. Failure to provide t his information may result in a delay in processing your request. American LegalNet, Inc. www.FormsWorkFlow.com Release of information I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medica l provider or facility, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, i ts agents and attorneys, any and all information or records, including all prior records as well as those pertaining to mental h ealth, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding m y injury, including request for conclusions and opinions not otherwise contained within existing medical records. y 20 U.S.S 21 Se c. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulation s. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of reso l ving claims against third parties. I authorize the release of any medical information related to my claim to my employer. Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fine s, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured employees , em ployers, medical providers, and attorneys. American LegalNet, Inc. www.FormsWorkFlow.com