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Physical Capabilities Worksheet. ERTW Physician's Response Please complete this form after your examination of the patient.Return completed form to: Encova Insurance. This form is presented as an alternative for the treating physician to provide a detailed statement regarding the injured worker's work restrictions. Attending Physician Statements are key to verifying your disability claim. Instructions for the Employee: Please provide this form to your physician to be completed and signed. You must submit this completed and signed form to your. Statement of Health. Physician's Response Please complete this form after your examination of the patient. Failure to complete this form may result in a delay in processing the claim.