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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How to fill out the NY Estimated Physical Capabilities Form online
This guide provides comprehensive instructions on how to fill out the NY Estimated Physical Capabilities Form online. Follow these steps to ensure accurate and complete submission of the form based on the individual's physical capabilities.
Follow the steps to successfully complete the NY Estimated Physical Capabilities Form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the name of the physician and the name of the employee in the designated fields. This information is crucial for identifying both parties involved in this evaluation.
- In section 1, indicate the medical diagnosis by providing the relevant details about the employee's condition.
- Proceed to section 2a. Here, you will check the appropriate boxes to indicate the number of hours the employee can stand, walk, and sit during an eight-hour workday, specifying whether these actions can be performed continuously or with rests.
- In section 2b, specify the total number of hours the employee can sit, stand, and/or walk in combination throughout a given day. Select from the options available.
- Navigate to the 'Other Capabilities' section. Check the appropriate boxes indicating how often the employee can carry various weights (e.g., 0-10 lbs, 11-20 lbs, etc.) and for tasks like crawling, lifting, and other movements.
- In the next section, indicate the dominant hand of the employee and whether they can perform repetitive actions such as grasping, pushing, pulling, and fine manipulation; select ‘Yes’ or ‘No’ as appropriate.
- Below that, evaluate the employee's lower extremities, specifically regarding their ability to use their feet/legs for repetitive movements, such as operating foot controls.
- In section 4, address work environment restrictions by answering questions about exposure to changes in temperature, unprotected heights, and moving machinery.
- Section 5 addresses other restrictions, such as the ability to restrain combative clients and any visual or hearing impairments that may require accommodation.
- Finally, in section 6, confirm if there are known problems or prescribed medications that could interfere with the employee's ability to return to work. Document the estimated time for the employee to return to full duty.
- Once all sections are completed, review the form for accuracy, then save changes. You can download, print, or share the form as necessary.
Complete the NY Estimated Physical Capabilities Form online to ensure proper assessment and documentation.
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