Capabilities form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Name of Physician' and 'Name of Employee' at the top of the form.
3. In section 1, provide the 'Medical Diagnosis' for the employee.
4. For section 2a, check the appropriate boxes indicating how many hours the employee can stand, walk, and sit during an eight-hour workday. Specify if these activities are continuous or with rests.
5. In section 2b, indicate the total hours for combined sitting, standing, and walking.
6. Proceed to 'Other Capabilities' and check boxes that apply regarding lifting weights and other physical tasks.
7. Complete sections on upper and lower extremities by answering questions about dominant hand usage and repetitive actions.
8. Fill out any work environment restrictions in section 4 and additional restrictions in section 5 as applicable.
9. Finally, provide comments regarding any known problems that may affect the employee's return to work in section 6.

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