West Virginia > Workers Comp

Physician Statement Of Physical Capabilities BI-PSPC - West Virginia

Physician Statement Of Physical Capabilities Form. This is a West Virginia form and can be used in Workers Comp .
 Fillable pdf Last Modified 6/3/2014
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Physician Statement Of Physical Capabilities Claimant Name: Claim Number: Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 Date of Injury: Please complete this form after your examination of the patient. Indicate the patient's restrictions, if any, including modified hours, duties, environmental factors and any other information pertinent to this employee's healthy recovery and possible early return to work. Medical Diagnosis: In an eight-hour workday, how many hours can this employee: Sit Stand 1 1 2 2 3 3 4 4 5 5 6 6 6 7 7 7 8 8 8 Continuously Continuously Continuously With Rests With Rests With Rests Walk 1 2 3 4 5 In a given day, how many total hours can this employee work? Upper Extremities Which hand is dominant? Right Left Can the employee perform these repetitive actions? Yes No Simple grasping Pushing and pulling R R L L R R L L Lower Extremities Can the employee perform repetitive actions to operate foot controls or motor vehicles? Yes Right Left No Simultaneous Right Yes Left No Lifting / Carrying 10 lbs. or less 11 ­ 20 lbs. 21 ­ 40 lbs. 41 ­ 60 lbs. 61 ­ 100 lbs. Pushing / Pulling 13 ­ 25 lbs. 26 ­ 40 lbs. 41 ­ 60 lbs. 61 ­ 100 lbs. 100+ lbs. Comments: Please indicate the extent to which the employee can perform the following: (N = Never, O = Occasionally, F = Frequently, C = Continuously) N O F C Activity N Bend Squat Kneel Twist / Turn Climb Crawl Reach Above Shoulder Type / Keyboard Driving Automatic Standard O F C Physician Name: Date released with above restrictions: Physician Signature: Physician Telephone: Date released for full-duty work: Date: Updated: 10/08 American LegalNet, Inc. www.FormsWorkFlow.com
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