Section B Additional Comments on Abilities and/or Restrictions From the date of this assessment, the above will apply for approximately: Have you discussed return to work with your patient? 1 2 Days 3 7 Days 8 14 Days 14 + days Yes No – – – Recommendations for d d m m y y y y Start Regular full-time Modified Graduated work hours and start Date: hours hours hours date: Section C Date of Next Appointment Recommended date of next appointment to review Abilities and/or Restrictions d d m m y y y y ► Treatment Plan: Estimated date for return to regular job duties: Thank you for your assistance in attending to our employee. Health Care Date: Practitioner’s Signature Health Care Name (Please Print) Practitioner’s Health Care Address and Practitioner’s Contact Information (Stamp if available)
Section B Additional Comments on Abilities and/or Restrictions From the date of this assessment, the above will apply for approximately: Have you discussed return to work with your patient? 1 – 2 Days 3 – 7 Days 8 – 14 Days 14 + days Yes No Recommendations for work hours and start date: Regular full-time hours Modified hours Graduated hours Start Date: d d m m y y y y Section C Date of Next Appointment Recommended date of next appointment to review Abilities and/or Restrictions ► d d m m y y y y Treatment Plan: Estimated date for return to regular job duties: Thank you for your assistance in attending to our employee. Health Care Practitioner’s Signature Date: Health Care Practitioner’s Name (Please Print) Health Care Practitioner’s Address and Contact Information (Stamp if available)
Functional-Abilities-Form-NON-OCC.docx