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: ___________________________________