www.labor.vermont.gov State of Vermont Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 Work Capabilities Form Form 20 Rev. 12/10 State File No.**: Ins. Co. File No.: Date of Injury: Form recommended for use by medical providers in assessing work capabilities of patients with work injuries Employee's Name: May Return to Work with NO RESTRICTIONS May Return to Work on Stand/Walk: Not at all Sit: Not at all Drive: Not at all Lift: Not at all No more than 10 lbs. No more than 20 lbs. No more than 50 lbs No more than 100 lbs. Unrestricted Bend: Not at all Squat: Not at all Climb: Not at all Twist: Not at all Reach above shoulders: Not at all 1-3 hours 1-3 hours 1-3 hours Based on my examination of this patient on: with the following capabilities: 3-5 hours 3-5 hours 3-5 hours 5-8 hours 5-8 hours 5-8 hours Unrestricted Unrestricted Unrestricted Occasionally Occasionally Occasionally Occasionally Frequently Frequently Frequently Frequently Occasionally Occasionally Occasionally Occasionally Occasionally Frequently Frequently Frequently Frequently Frequently Unrestricted Unrestricted Unrestricted Unrestricted Unrestricted Specific work capabilities not listed above: Employee has limited use of: Employee can cannot perform repetitive activities for more than ; or min/hrs. until further evaluation. Employee can cannot work more than 8 hours a day. Work capabilities are in effect until: May NOT RETURN TO WORK Scheduled for a follow-up appointment on: Referred to: Estimated duration of total disability: for follow-up care. Medical Provider's Name (Print) Date Medical Providers Signature AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize this medical provider to release any information acquired in the course of my examination or treatment for the above injury to my employer or its representative. Patient Signature: Date: ** If you do not have the state file number please contact the Department of Labor at (802) 828-2286. American LegalNet, Inc. www.FormsWorkFlow.com