Capabilities form 2025

1. Click ‘Get Form’ to open the capabilities form 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, indicate how many hours the employee can stand, walk, and sit during an eight-hour workday by checking the appropriate boxes.
5. In section 2b, specify the total hours for combined activities of sitting, standing, and walking.
6. Proceed to 'Other Capabilities' and check all applicable boxes regarding lifting and carrying weights.
7. Complete sections on upper and lower extremities by answering questions about repetitive actions and movement capabilities.
8. Fill out any work environment restrictions in section 4 and other restrictions in section 5 as necessary.
9. Finally, provide comments regarding any known problems that may affect return to work in section 6, along with your contact information.

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