Free WORKERS' COMPENSATION WORK CAPABILITIES FORM - Vermont


File Size: 23.3 kB
Pages: 1
Date: April 18, 2007
File Format: PDF
State: Vermont
Category: Workers Compensation
Author: Krista J. Gravel
Word Count: 327 Words, 2,937 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://labor.vermont.gov/Portals/0/WC/Form20.pdf

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STATE OF VERMONT DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION 5 GREEN MOUNTAIN DRIVE, PO BOX 488 MONTPELIER, VT 05601-0488 (802) 828-2286
www.labor.vermont.gov

DOL FORM 20
State File No. Ins. Co. File No. Date of Injury Fed. ID No. ___ ___ ___ ___

Rev 5/05
_______________ _______________ _______________ _______________

Soc. Sec. No. ___ _______________ WORK CAPABILITIES FORM Form recommended for use by medical providers in assessing work capabilities of patients with work injuries

Employee's Name: __

____________________________________________

Based on my examination of this patient on _

_____________________(date)

May NOT RETURN TO WORK May Return to work with no restrictions May Return to work on _ ____________with the following capabilities: WORK CAPABILITIES ­ may perform the following: (a) Stand/Walk: Not at all (b) Sit: Not at all (c) Drive: Not at all (d) Lift: Not at all No more than 10 lbs. No more than 20 lbs. No more than 50 lbs. No more than 100 lbs. Unrestricted (e) Bend: Not at all (f) Squat: Not at all (g) Climb: Not at all (h) Twist: Not at all (i) Reach above shoulders: Not at all

1-3 hrs 1-3 hrs 1-3 hrs

3-5 hrs 3-5 hrs 3-5 hrs

5-8 hrs 5-8 hrs 5-8 hrs

Unrestricted Unrestricted Unrestricted

Occasionally Occasionally Occasionally Occasionally

Frequently Frequently Frequently Frequently

Unrestricted Unrestricted Unrestricted Unrestricted

Occasionally Occasionally Occasionally Occasionally Occasionally

Frequently Frequently Frequently Frequently Frequently

Unrestricted Unrestricted Unrestricted Unrestricted Unrestricted

Specific work capabilities not listed above:_ _____________________________________________________________. Employee has limited use of: __ ______________________________________________________________________. Employee Employee can can cannot perform repetitive activities for more than _ cannot work more than 8 hours a day. until _ _____________;or ________ min/hrs.

Work capabilities are in effect

until further evaluation:

Scheduled for follow-up appointment on __ Referred to _

______________________________________________________.

______________________________________________________ for follow-up care. _______________________________________________________.

If disabled at this time, estimate duration of total disability:_ Comments: _

___________________________________________________________________________________________

_______________________________________________________________________________________________________
Medical Provider's Name (Print) Medical Providers Signature Date

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize this Medical Provider to release any information acquired in the course of my examination or treatment for the above injury to my employer or its representative. Patient Signature: ________________________________________________Date: ___________________________________