Functional Capacity Assessment

G. REMARKS:

(Please use this space to explain or clarify any of the preceding information.) Describe any specific

limitations or restrictions for any of the above categories and list any assistive devices, equipment, or

accommodation the employee requires to perform his or her job:

___________________________________________________ _________________________

Physician’s/Practitioner’s Signature Date

___________________________________________________ _________________________

Name of Practice Type of Practice

___________________________________________________ _________________________