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Click ‘Get Form’ to open it in the editor.
Begin by entering the employee's name and the date of their last appointment in the designated fields.
Fill in the claim number and next office visit date to ensure accurate tracking of the case.
Indicate the job title and specify if the employee can return to work full duty without restrictions, or list any restrictions if applicable.
Complete the weight capacity section by indicating how much weight (in lbs) the patient can lift, carry, push, or pull for specified durations.
Mark whether the patient can perform various physical activities such as bending, climbing stairs, and using hands repetitively by placing an 'X' in the appropriate boxes.
Specify any additional limitations or recommendations that may affect the employee's return to work.
Finally, ensure that a physician's signature is included along with their printed name, specialty, and date before submitting.

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