Worker Name: / Claim Number(s):
Department of Labor and Industries
Fax completed forms to 360-902-4567 / / Functional Capacity Summary

Functional Capacity Evaluator:

Complete and return this form to L&I within 10 days of the evaluation.

Worker Name: / Evaluation Date(s): / Claim Number(s):
Accepted Conditions:
Were there any limitations due to unrelated factors that impacted your results?
No Yes (if yes, describe on page 2)
Projected Work Tolerance:
Hours per day / Total hours per week
Sit for / Select OneHoursMinutes at a time / Hours per day
Stand for / Select OneHoursMinutes at a time / Hours per day
Walk for / Select OneHoursMinutes at a time / Hours per day
Alternately sit/stand/walk for / Select OneHoursMinutes at a time / Hours per day
Alternately stand/walk for / Select OneHoursMinutes at a time / Hours per day
Comments:
Task
R = Right; L = Left; B = Both
Hand Dominance: R L / Never / Seldom
1 – 10%
0 – 1 hour / Occasional
11 – 33%
1 – 3 hours / Frequent
34 – 66%
3 – 6 hours / Constant
67 – 100%
Not restricted / Not Tested
Perform Work on Ladders / XRLB / XRLB / XRLB / XRLB / XRLB / X
Climb Ladders / XRLB / XRLB / XRLB / XRLB / XRLB / X
Climb Stairs / XRLB / XRLB / XRLB / XRLB / XRLB / X
Twist Neck / XRLB / XRLB / XRLB / XRLB / XRLB / X
Twist Trunk / XRLB / XRLB / XRLB / XRLB / XRLB / X
Bend/Stoop / XRLB / XRLB / XRLB / XRLB / XRLB / X
Kneel / XRLB / XRLB / XRLB / XRLB / XRLB / X
Squat Partial Full / XRLB / XRLB / XRLB / XRLB / XRLB / X
Crawl – Distance: ft. / XRLB / XRLB / XRLB / XRLB / XRLB / X
Reach Forward / XRLB / XRLB / XRLB / XRLB / XRLB / X
Reach Waist to Shoulder / XRLB / XRLB / XRLB / XRLB / XRLB / X
Work Above Shoulders / XRLB / XRLB / XRLB / XRLB / XRLB / X
Keyboarding / XRLB / XRLB / XRLB / XRLB / XRLB / X
Wrist (Flexion/Extension) / XRLB / XRLB / XRLB / XRLB / XRLB / X
Grasp (Forceful) / XRLB / XRLB / XRLB / XRLB / XRLB / X
Handle/Grasp / XRLB / XRLB / XRLB / XRLB / XRLB / X
Fine Manipulation / XRLB / XRLB / XRLB / XRLB / XRLB / X
Operate Foot Controls / XRLB / XRLB / XRLB / XRLB / XRLB / X
Vibrations – High Impact / XRLB / XRLB / XRLB / XRLB / XRLB / X
Vibrations – Low Impact / XRLB / XRLB / XRLB / XRLB / XRLB / X
Lifting – Floor to Waist / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Lifting – Waist to Shoulders / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Lifting – Shoulder to Overhead / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Lifting – Other: / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Carry – Distance: ft. / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Push – Dynamic Dist: ft. / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Pull – Dynamic Dist: ft. / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Other: / XRLB / XRLB lbs. / XRLB lbs. / XRLB lbs. / XRLB lbs. / X
Comments Related to Capacity Grid Above:

Per L&I Guidelines, capacity grid above was not completed as unable to make return to work conclusions.

Functional Capacity Summary

Clinic Name: / Clinic Phone Number:
Clinic Address:
Job of Injury Title: / Date of Injury:
Date of Authorization: / Attending Provider:
Vocational Provider: / Referring Provider:

Evaluator Conclusions:

Based on the worker’s performance and reliability measurements of this evaluation, are you able to make return to work conclusions? If no, don’t fill out the next two sections or Capacity Summary on page 1.

Yes / Explain:
No / Explain:

Responses to Job Analysis/Job Description:

F245-434-000 Functional Capacity Summary 01-2016 Index: VOC

Worker Name: / Claim Number(s):
Job Analysis Title / Is the worker able to perform this job?
(Yes or No) / If no, describe what physical demand task is limited and based on what objective claim related factor. / If no, are any limitations due to unrelated factors (other conditions, behaviors, etc.)? Describe impact on physical demand task.
1. / Job of Injury
2.
3.
4.
5.

F245-434-000 Functional Capacity Summary 01-2016 Index: VOC

Worker Name: / Claim Number(s):

F245-434-000 Functional Capacity Summary 01-2016 Index: VOC

Worker Name: / Claim Number(s):

Other Referral Questions:

List and answer any additional questions asked by the claim manager, vocational provider, employer, and/or attending provider.

Attending Provider Evaluation Restrictions:

None/Test to Tolerance / Lifting Restriction: / Cardiac Precautions:
Other (please describe):

Additional Observations/Comments:

Evaluation Length:

Hours/ Days

Signature:

Print Evaluator(s) Name / Evaluator(s) Signature / Date

F245-434-000 Functional Capacity Summary 01-2016 Index: VOC