Functional Capacity Evaluation Form PDF Details

Fitness to work assessments are often required by insurance companies and other organizations before an individual is cleared to return to work after an injury. In some cases, a functional capacity evaluation (FCE) may be necessary in order to assess an individual's ability to resume their normal activities. The FCE form is used to evaluate an individual's physical abilities and limitations. This form can be used by physicians, therapists, or other licensed professionals who are qualified to complete this type of evaluation. By completing the FCE form, professionals can provide detailed recommendations about the individual's ability to return to work. The information contained in this article is for educational purposes only and should not be construed as legal advice. Always consult with a competent attorney regarding any specific legal issues you may have. Copyright © 2018-present | Legal123, Inc. All rights reserved worldwide. No part of this publication may be reproduced witho

QuestionAnswer
Form NameFunctional Capacity Evaluation Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfunctional capacity evaluation form, functional eval test, estimated functional capacity evaluation, estimated evaluation

Form Preview Example

ESTIMATED FUNCTIONAL CAPACITY EVALUATION

 

To be completed by treating physician.

 

 

 

 

 

 

 

 

 

 

Patient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitions for your reference:

 

 

 

SEDENTARY WORK:

lift 10# maximum and occasionally carry small objects

LIGHT WORK:

lift 20# maximum; frequently lift/carry up to 10#

 

 

MEDIUM WORK:

lift 50# maximum; frequently lift/carry up to 25#

 

 

HEAVY WORK:

lift 100# maximum; frequently lift/carry up to 50#

 

 

VERY HEAVY WORK:

lift in excess of 100#; frequently lift/carry 50#

 

 

I WOULD ESTIMATE THIS PERSON TO BE ABLE TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Never

 

Occasionally

 

Frequently

Continuously

 

 

 

 

(1-33%)

 

(34-66%)

(67-100%)

 

 

 

 

 

 

 

 

 

1. LIFT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. up to 10#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. 11 - 24#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. 25 - 34#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. 35 - 50#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. 51 - 74#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. 75 - 100#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. CARRY:

 

 

 

 

 

 

 

 

 

 

 

 

 

a. up to 10#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. 11 - 24#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. 25 - 34#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. 35 - 50#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. 51 - 74#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. 75 - 100#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. PERFORM THE FOLLOWING TASKS:

 

 

 

 

 

 

 

 

 

 

 

 

 

Push/Pull – Seated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Push/Pull – Standing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bend

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Squat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Crawl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Climb

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reach above shoulder level

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.ASSUMING AN 8-HOUR WORKDAY WITH TWO 15-MINUTE BREAKS AND AN HOUR MEAL BREAK, I WOULD EXPECT THIS PERSON TO BE ABLE TO:

Circle number of hours for each activity. NOTE: Total does NOT have to equal 8 hours.

Activity

Sit

Stand

Walk

Alternately Sit/Stand

 

 

 

Number of Hours

 

 

 

Continuously

With Rests

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6

7

8

 

1

2

3

4

5

6

7

8

 

1

2

3

4

5

6

7

8

 

1

2

3

4

5

6

7

8

 

 

 

 

 

 

 

 

 

 

 

 

 







5.CAN PERSON USE HANDS FOR REPETITIVE ACTIONS SUCH AS:

 

Simple Grasping

 

Firm Grasping

Fine Manipulating

 

 

 

 

 

 

 

 

Right:

Yes

No

 

Yes

No

Yes

No

Left:

Yes

No

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

Estimated Grip Strength:

Right:

# Left:

#

 

 

 

 

 

 

 

 

 

 

6.CAN PERSON USE FEET FOR REPETITIVE MOVEMENTS AS IN OPERATING FOOT CONTROLS?

 

Right (Alone)

 

 

Left (Alone)

Both (Simultaneously)

 

Yes

No

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

7.

ANY RESTRICTIONS OF ACTIVITIES INVOLVED?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Activity

 

 

None

 

Mild

Moderate

Total

 

 

 

 

 

 

 

 

 

 

Unprotected Heights

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Being around moving machinery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exposure to marked changes in

 

 

 

 

 

 

 

 

temperature and humidity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driving automotive equipment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exposure to dust; fumes; gases

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.CAN PERSON CONTINUE IN CURRENT JOB? Yes No

If not, can person return to other work according to restrictions defined above? Yes No Can the person work full-time? Yes No

If not, can the person work part-time? Yes No

If person can work part-time but not full-time, please estimate schedule, in hours per day and days per week:

Disability rating (if applicable):

%

 

 

9.COMMENTS:

Physician Name:

Address:

City, State, Zip:

Telephone:

Field of Specialty:

License No.:

 

 

 

Signature:

 

Date:

 

 

 




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1. Complete your functional capacity evaluation form with a group of major blanks. Note all of the required information and make certain nothing is overlooked!

Completing segment 1 in estimated functional capacity evaluation

2. After this section is done, you're ready put in the needed details in a up to, PERFORM THE FOLLOWING TASKS, PushPull Seated, PushPull Standing, Bend, Squat, Crawl, Climb, Reach above shoulder level, ASSUMING AN HOUR WORKDAY WITH TWO, Circle number of hours for each, Sit, Stand, Walk, and Activity so you're able to go further.

Filling out segment 2 of estimated functional capacity evaluation

3. In this particular stage, look at Walk, and Alternately SitStand. These are required to be filled out with highest accuracy.

estimated functional capacity evaluation conclusion process described (portion 3)

4. To go ahead, the next stage will require filling out a few empty form fields. These include Right, Left, Simple Grasping, Yes, Yes, Firm Grasping, Yes, Yes, Fine Manipulating, Yes, Yes, Estimated Grip Strength Right, CAN PERSON USE FEET FOR REPETITIVE, Right Alone, and Yes, which are fundamental to moving forward with this particular form.

Ways to fill in estimated functional capacity evaluation stage 4

As to Yes and Yes, make sure that you don't make any errors here. These two are surely the most important ones in the PDF.

5. This document has to be finalized by going through this area. Further there can be found a comprehensive set of blank fields that require correct details in order for your form submission to be complete: If not can person return to other, Can the person work fulltime Yes, If not can the person work, If person can work parttime but, Disability rating if applicable, COMMENTS, Physician Name, Address, City State Zip, Telephone, Field of Specialty, and License No.

Completing section 5 in estimated functional capacity evaluation

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