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  • Ny Estimated Physical Capabilities Form 1996

Get Ny Estimated Physical Capabilities Form 1996-2025

I. Name of Physician Name of Employee Note Important Information on Reverse 3TRUCTIONS If the employee is found to be 50 or less disabled please complete this form based on your estimation of islher current physical capabilities. 1. Medical Diagnosis 2 a* In an eight-hour workday how many hours can this employee Please check appropriate boxes. Stand 01 Walk 01 Sit o Continuously o With Rests b. In a given day for how many total hours can this employee sit stand and/or walk in combination D 4 D 6 Other Capabilities Please check appropriate boxes. N ever 0 ccasona IIv Freauentlv 11-20Ibs. 21-50Ibs. 51-100Ibs. Carrv 00-101bs. D md dQuat I Crawl D 16 C ontlnuouslv Lift Upper extremities o Which hand is dominant Can this employee perform repetitive actions such as Simple Grasping RIGHT OVes LEFT DVes Right Pushing Pulling D No DVes 0 No OVes Left Fine Manipulation No Climb Run Reach above shoulder level Operate a motor vehicle Lower Extremities Use of feeVlegs for repetitive movement as in ....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232