Functional abilities form template 2025

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The document is a Functional Abilities Form used by the Renfrew County Catholic District School Board to assess an employee's capacity to return to work after an illness. It includes sections for personal information, medical evaluation by a health professional, and details on physical capabilities and limitations. The form aims to facilitate a timely and safe return to work by outlining any necessary accommodations or restrictions.

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Click ‘Get Form’ to open the functional abilities form template in the editor.
Begin by entering the employee’s name, S.I.N., full home address, date of birth, and contact information in the designated fields.
Fill in the position prior to absence and the first consecutive date of absence due to illness.
Health professionals should complete their section, including the date of examination and details about rehabilitation or treatment required.
Indicate whether the employee can return to work immediately without restrictions by selecting 'YES' or 'NO'. If 'NO', provide general comments and specific limitations.
Detail capabilities related to walking, standing, sitting, lifting, stair climbing, and other physical activities by checking appropriate boxes.
Complete sections on limitations regarding bending, twisting, chemical exposure, and any medication restrictions.
Provide recommendations for work hours and estimated duration of limitations. Include health professional’s name and signature at the end.

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What are the two most commonly used measures of functional ability?

A functional status assessment should be performed using a standardized, validated assessment tool. Two commonly utilized tools are the Katz Index of Independence in Activities of Daily Living (Katz ADL Index) and the Lawton-Brody Instrumental Activities of Daily Living Scale (Lawton Scale for IADL).

What are functional abilities at Costco?

The Functional Abilities Form (FAF) is a tool used by Costco to assess an employees functional abilities and limitations in order to determine their suitability for specific job tasks.

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The GARNet index measures items in each of the following five domains of aging well: physical health and functional status; mental/cognitive effectiveness; social support resources; daily life activity; and material security. A broad range of research and theoretical literature supports the importance of each domain.

What is the functional abilities form?

This form, when completed, is used to enable an employer to accommodate an ill or injured employee to remain at, or if absence is unavoidable, to return to work as soon as they are safely able to do so.

What is a normal functional ability?

An individuals ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being.

non occupational functional abilities form

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What are the categories of functional abilities?

The FAI model includes eight categories of functional abilities: dependent, frail, pre-frail, lower independent, higher independent, semi fit, fully fit and elite. Its important to note that this model represents a continuum of function, so even within each category there is variability.

What are the 5 levels of functional ability?

As crucial abilities that enable individuals to achieve well-being, the WHO proposed five domains of functional ability, including the ability to meet basic needs; learn, grow and make decisions; move around; build and maintain relationships and contribute [2].

What is an example of a functional ability?

Functional ability consists of the intrinsic capacity of the individual, relevant environmental characteristics and the interaction between them. Intrinsic capacity comprises all the mental and physical capacities that a person can draw on and includes their ability to walk, think, see, hear and remember.