Wisconsin > Workers Comp
Estimated Functional Capacities DOA-6041 - Wisconsin
| Estimated Functional Capacities Form. This is a Wisconsin form and can be used in Workers Comp . |
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STATE OF WISCONSIN DEPARTMENT OF ADMINISTRATION DOA-6041 (R05/2007) BUREAU OF STATE RISK MANAGEMENT DIVISION OF ENTERPRISE OPERATIONS Estimated Functional Capacities Name State Agency Please complete the following items based on your estimated clinical evaluation. If you have any questions regarding this form please call: Name Telephone Number 1. In an 8 hour workday (Includes a 15 min. break/4 hours; and ½ hour lunch/8hour work shift.) the patient/employee can: (indicate full capacity for each activity) N/A 1 Hr 2 Hrs 3 Hrs 4 Hrs 5 Hrs 6 Hrs 7 Hrs 8 Hrs Never Continuously Sit Stand Walk 2. Indicate the capacity in which the patient/employee can do each of the following activities. N/A Never Continuously N/A Lift 10 lbs Bend 11-20 lbs Squat 21-50 lbs Crawl 51-100 lbs Climb Carry 10 lbs Reach Above 11-20 lbs Shoulder Level 21-50 lbs 51-100 lbs Patient/employee can use hands for repetitive actions such as: Simple Grasping N/A Yes No Right Left Pushing & Pulling Yes No Never Continuously 3. Fine Manipulating Yes No 4. Patient/employee can use feet for repetitive movements as in operating foot controls: N/A Yes No Right Left Both Restriction of activities involving: N/A Unprotected Heights Being Around Moving Machinery Exposure to Marked Changes in Temperature & Humidity Operation of Motor Vehicles Operation of Industrial Equipment Operation of Heavy Custodial Equipment 1. Auto-scrubber 2. Single-disc floor machine - 20" 3. Carpet Extractor 4. 14" Vacuum Cleaner Exposure to Dust, Fumes, Gases and Cleaning Chemicals None Mild Moderate Total 5. Can patient now work? Physician's Signature Yes No Full-time Part-time (4 hrs/day) Date (mm/dd/ccyy) Please Attach Additional Comments American LegalNet, Inc. www.FormsWorkflow.com
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