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Get Capabilities And Limitations Dification Form

CK ink. Employee Name (Last, First, Middle Initial) Gender Male Social Security Number Date of Birth (MM/DD/YYYY) Job Title Control Number Female 622715 Current Diagnosis Medications: Indicate the percent of the day the following activities can be performed: (Occasional 1-33% or .5-2.5 hrs. Frequent 34-66% or 2.6-5.0 hrs. Continuous 67-100% or 5.1-8 hrs. or Never) O F C N O Climbing Hand Grasping R L Crawling Firm Hand Grasping R L Kneeling Fine Manipulation R L Lifting Gross Manipulat.

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