Get Activity Prescription Form

The Activity Prescription Form is essential for documenting a worker's activity status and restrictions after an injury. This guide provides step-by-step instructions on completing the form online to ensure accurate submission and support for the individual’s recovery.

Follow the steps to successfully complete the Activity Prescription Form online.

1. Press the 'Get Form' button to access the Activity Prescription Form and open it on your device.
2. Begin filling out the general information section, including the worker's name, visit date, claim number, and healthcare provider’s name. Ensure all fields are completed accurately.
3. Indicate the date of injury and provide a relevant diagnosis. Choose one of the options for the worker’s work status — whether they are released for work or may perform modified duties.
4. Complete the Key Objective Findings section by estimating the worker's physical capacities. This information is crucial for time-loss payment decisions.
5. If necessary, provide details for temporary or permanent restrictions, including specifics about the worker's abilities regarding sitting, standing, walking, and other physical tasks.
6. Make sure to indicate whether the employer has been notified of the worker's restrictions and whether modified duties are available.
7. Document any additional remarks in the notes section, including information relevant to the worker's treatment and rehabilitation progress.
8. Review the form for completeness. Once all fields are filled out, you can save your changes, download, print, or share the form as needed.

Complete the Activity Prescription Form online today to facilitate the worker’s recovery process.