The Physical Capabilities form serves as a critical tool for assessing an employee’s ability to perform work-related tasks following an injury or illness. Completed by a physician, it offers a comprehensive evaluation of an employee's capacity by addressing various physical demands, including the ability to sit, stand, walk, lift, carry, push, and pull, along with the endurance to perform these activities over an eight-hour workday. Not only does it inquire about the employee's ability to perform repetitive actions with their upper and lower extremities, but it also delves into their capacity to engage in activities that require fine manipulation and the operation of motor vehicles. Additionally, the form evaluates potential work environment restrictions, such as exposure to extreme temperatures, humidity, and moving machinery, as well as other specific restrictions like dealing with combative clients or working at unprotected heights. Furthermore, it assesses any visual or hearing impairments that might necessitate special accommodations. Physicians are also asked to note any general health issues exacerbated by prescribed medications or treatments that could impede the employee’s return to work, providing a space for them to estimate when the individual might be able to resume full duty. This careful documentation is essential for employers to make informed decisions regarding workplace accommodations and the safety and well-being of their employees.
| Question | Answer |
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| Form Name | Physical Capabilities Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | physical capability form, ny estimated capabilities, ny physical capabilities state form, ny estimated physical state pdf |
IName of Physician |
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IName of Employee |
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Note: Important |
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3TRUCTIONS: If the employee |
is found to be 50% or less disabled, please complete |
this form based on your estimation of |
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),islher current physical capabilities. |
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1. |
Medical Diagnosis: |
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2 a. In an |
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Sit |
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o Continuously |
o With Rests |
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Stand |
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0304 |
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o Continuously |
o With Rests |
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Walk |
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o Continuously |
o With Rests |
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b. In a given day, for how many total hours can this employee sit, stand, and/or walk in combination? |
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D 6 |
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0 8 |
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0 12 ' |
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D 16 |
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3.Other Capabilities: (Please check appropriate boxes.)
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Never |
0ccasonaI IIv |
FreauentlvI |
Contlnuouslv |
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Lift |
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Upper extremities: |
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O Right |
O Left |
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Which hand is dominant? |
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Can this employee perform |
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repetitive actions such as: |
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Carrv |
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Simple |
Pushing |
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Fine |
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Grasping |
& Pulling |
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Manipulation |
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RIGHT |
OVes |
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No |
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No |
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No |
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LEFT |
DVes |
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No |
OVes |
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No |
DVes |
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No |
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md |
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dQuat |
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Lower Extremities: |
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I Crawl |
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Use of feeVlegsfor repetitive movement, as in |
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Climb |
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operation of foot controls and motor vehicles. |
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Run |
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Reach above |
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Simultaneous |
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Extremity |
Extremity |
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shoulder level |
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Operate a |
D |
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OVes |
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DVes |
0 No |
OVes |
0 No |
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motor vehicle |
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4. |
Work Environment Restrictions: |
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Can this employee: |
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Be exposed to marked changes in temperature and humidity? |
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No |
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Be exposed to unprotected heights? |
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0 No |
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Be around moving machinery? |
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0 No |
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5. |
Other Restrictions: |
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0Ves |
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0 No |
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Can this employee restrain combative clients? |
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0 No 0Ves |
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Does this employee have any visual or hearing impairment requiringaccommodation? |
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If "Yes, " |
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please |
explain: |
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6.Based on your examination(s) of this employee, are there any known problems of a general nature, including any medications
prescribed for the diagnosis listed, that would interfere with this employee returning to work?
O No 0 Ves If "Yes,"please explain:_
'Vhen,in your estimation, will this employee be ready to return to full duty? Date |
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;omments: |
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TelephoneNumber |
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