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Get NY Estimated Physical Capabilities Form 1996-2024

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 operation of foot controls and motor vehicles. Extremity OVes 4. Work Environment Restrictions Be exposed to marked changes in temperature and humidity 0 Ves Be exposed to unprotected heights Be around moving machinery 5. Other Restrictions Does this employee have any visual or hearing impairment requiring accommodation please explain Simultaneous If Yes 6. Based on your examination s of this employee are there any known problems of a general nature including any medications prescribed for the diagnosis listed that would interfere with this employee returning to work No 0 Ves If Yes please explain Vhen in your estimation will this employee be ready to return to full duty omments Date Telephone Number. 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. 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 operation of foot controls and motor vehicles. 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 operation of foot controls and motor vehicles. Extremity OVes 4. Work Environment Restrictions Be exposed to marked changes in temperature and humidity 0 Ves Be exposed to unprotected heights Be around moving machinery 5. .

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