Functional Capacity Assessment

RELEASE OF INFORMATION
I, _________________________________, hereby authorize _________________________, physician/
(Please PRINT) (Please PRINT)
practitioner, to furnish written information to ______________________________________________,
my employer, regarding my residual functional capacity, any limitations or restrictions on my ability to
perform the functions of my position and any devices, equipment, or accommodations I require to enable
me to perform these functions.
Employee’s Signature ____________________________________________ Date _________________
FUNCTIONAL CAPACITY ASSESSMENT
Physician/Practitioner - Please confine your completion of this form to only those elements that are
pertinent to the employee’s ability to perform the essential functions of his/her job. Explain any limitations
in Section G.
Genetic Information Nondiscrimination Act of 2008 Notice
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are
asking that you not provide any genetic information when responding to this request for medical
information. “Genetic Information” as defined by GINA includes an individual's family medical history, the
results of an individual's or family member's genetic tests, the fact that an individual or an individual's
family member sought or received genetic services, and genetic information of a fetus carried by an
individual or an individual's family member or an embryo lawfully held by an individual or family member
receiving assistive reproductive services.
A. POSTURAL LIMITATIONS:
Continuously Frequently Infrequently Never
(4-6 hrs./day) (2-6 hrs./day) (0-2 hrs./day)
Sitting G G G G
Standing G G G G
Walking G G G G
Bending G G G G
Climbing G G G G
Reaching G G G G
Squatting/Stooping G G G G
Crawling G G G G
Kneeling G G G G
B. PHYSICAL EXERTION LIMITATIONS:
Up to 10 lbs. 10 lbs. to 25 lbs. 25 lbs. to 50 lbs. Over 50 lbs.
Lifting G G G G
Carrying G G G G
Pushing/Pulling G G G G
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