Get Nc Denr Work Ability Evaluation Form 2002-2026

Completing the NC DENR Work Ability Evaluation Form is an essential step in assessing an injured employee's capacity to work. This guide aims to provide clear and supportive instructions for filling out the form online, ensuring that users can navigate the process with ease.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the injured employee's name in the designated fields for first, middle, and last names. This information is crucial for identification.
3. Next, input the date of the injury in the appropriate section, ensuring accuracy to align with the case details.
4. Provide a clear description of the employee's current job, including specific roles and responsibilities, to ensure a comprehensive evaluation.
5. In the activity section, check the frequency of activities the employee can perform. Mark 'Continuous' or 'Intermittent' for each listed activity according to the employee's capabilities.
6. Indicate the number of hours per day the employee is able to perform each activity by selecting the appropriate number from the provided options.
7. For restrictions on lifting, select the applicable weight categories. Indicate whether there are hand restrictions, and specify the nature of any such restrictions if applicable.
8. Answer questions concerning the employee's ability to reach, operate vehicles, and perform various functions, providing explanations for 'yes' responses in the space provided.
9. Document any limitations that may affect the employee’s ability to work, such as cardiac, visual, or hearing issues.
10. Complete the sections related to the employee's capacity to instructions and deadlines, and whether they can work a full eight-hour shift.
11. Provide assessments about the need for vocational services for the employee's return to work, and whether they have reached Maximum Medical Improvement (MMI), noting any dates as required.
12. Include any remarks or additional comments related to the employee's medical condition or job restrictions.
13. Finalize the form by having the healthcare provider complete their statement, including name, address, and signature, certifying the accuracy of the information provided.
14. After completing all sections, save changes, download, print, or share the form as needed to ensure all stakeholders have access to the necessary documentation.

Begin filling out the NC DENR Work Ability Evaluation Form online today for a smooth evaluation process.