DEP Physician's Report of Work Ability INStRUCtIONS: · Complete the items below on your clinical evaluation and other testing results of the injured worker per an eight-hour workday. · Check appropriate boxes as you complete this form. Injured worker name Injured worker occupation Claim number Employer name Social Security number if claim number unknown Date of injury / / Work/Non-work capabilities % of workday (8 hours) None at all Repetitions per hour 0% Lift/carry Up to 10 lbs. ................................................... 11-20 lbs. ........................................................ 21-50 lbs. ........................................................ 51-100 lbs. ...................................................... Bending.......................................................... Twist/turn....................................................... Reach below knee ....................................... Push/pull ........................................................ Squat/kneel ................................................... Stand/walk .................................................... Sit .................................................................... Lifting above shoulders ............................... Hand restrictions Left Right Must wear splint No lifting greater than_______ lbs No repetitive activities No work with hot or cold substances No use of Left Right Arm Hand Finger ______ Other ___________________ Occasional 1%-33% 4-6 Frequent 34%-66% 6-12 Continuous 67%-100% >12 WORk ACtIvIty Are the restrictions temporary permanent If temporary, give an opinion as to the expected duration of the restrictions: from __________ to __________ Due to the restrictions noted above, how many total hours per day and per week is the injured worker able to work? ________ Hours ________ Days Physician's further explanation of work abilities or why the injured worker is unable to perform any work: I certify the above information is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both. Physician signature Date (mandatory) // BWC-1270 (6/2/2004) C-143 American LegalNet, Inc. www.FormsWorkFlow.com