FUNCTIONAL ABILITIES Sample Clauses

FUNCTIONAL ABILITIES. PLEASE INDICATE ANY DIRECT MEDICAL/HEALTH CONTRAINDICATIONS (RISK, HARM OR DANGER) TO PERFORMING ANY OF THE TASKS LISTED BELOW. INDICATE THE REASON. Physical No Contraindication Limited Duration Limited Frequency Complete Contraindication Reason/Limitation (Include Weight Restrictions) Standing     Sitting     Walking     Carrying     Explain: Psychological/Cognitive N/A Seldom Infrequent Occasional Frequent Constant Unable to do (explain) Remember locations and routine procedures        Xxxxxxxxxx and remember short and simple instructions        Xxxxxxxxxx and remember detailed instruction        Xxxxxxxx xxxxxxxxx and concentration for extended periods        Xxxxxxx xxxxxxxxxx within a schedule        Xxxxxxx an ordinary routine without supervision        Make simple decisions        Xxxxx simple straightforward problems        Xxxxx complex problems        Xxxx with conflict situations        Xxxxxxx to frequent changes in the environment        Get along well with others without distracting them        Cope with students in stressful situations        Xxxxxxxx deadline pressures        Other (please specify)        Xxxxxxx: PROGNOSIS What is the expected duration of functional recovery for your patient’s condition?  Days  Weeks  Months Please specify: If you were presented with a plan for a modified return to work, would you be able to assist us in defining the medical limitations, or would a specialist referral be required?  Yes  No, specialist input required. Have you discussed recovery/return to work (RTW) expectations with your patient? Yes No Expected RTW date: REMARKS PROVIDE ANY ADDITIONAL DETAILS WHICH WOULD BE HELPFUL TO OUR ASSESSMENT OF YOUR PATIENT’S LIMITATIONS/REQUIREMENTS FOR ACCOMMODATION PHYSICIAN IDENTIFICATION Name of Attending Physician (Please Print): Telephone No: ( ) Address: Street City Province Postal Code Physician’s Signature: Date (dd-mm-yyyy): Once completed this form is to be returned to Human Resources by: Confidential Fax: 000-0000, or, mail to: Xxxxxx Xxxxxx Mount Saint Xxxxxxx University 000 Xxxxxxx Xxxxxxx Xxxxxxx, XX X0X 0X0 DATED at Halifax, Nova Scotia this day of , 2017 Mount Saint Xxxxxxx University Canadian Union of Public Employees Board of Governors Local 3912
Sample 1
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FUNCTIONAL ABILITIES. Walking (continuously): □ up to 20 min; □ up to 1 hour; □ no restriction; □ Other (e.g., uneven ground) Standing (continuously): □ up to 20 min; □ up to 1 hour; □ no restriction; □ Other Sitting (continuously): □ up to 30 min; □ up to 1 hour; □ no restriction; □ Other Stair climbing: □ unable □ 2 – 3 steps only; □ own pace □ assisted □ no restriction Lifting floor to waist: □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Lifting waist to shoulder: □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Carrying □ up to 20 lbs; □ up to 30 lbs □ up to 40 lbs; □ no restriction; □ Other Reaching (please specify) □ no restriction; □ Other Bending – repetitive (please specify) □ no restriction; □ Other Limited ability to used left hand to: □ hold objects; □ grip; □ type; □ write Limited ability to used right hand to: □ hold objects; □ grip; □ type; □ write Completely unable to use left hand to: □ hold objects; □ grip; □ type; □ write Completely unable to use right hand to: □ hold objects; □ grip; □ type; □ write Hours per day: □ 4 hours □ 6 hours □ 8 hours COGNITIVE ABILITIES: □ no restriction □ less then 4 hours (specify) Twisting – repetitive (please specify) □ no restriction; □ Other Employee is: □ Left handed □ Right handed □ Ambidextrous Concentration □ limited capacity □unable to perform □ no restriction; □ Other Attention □ limited capacity □unable to perform □ no restriction; □ Other Memory □ limited capacity □unable to perform □ no restriction; □ Other Organization/Planning □ limited capacity □unable to perform □ no restriction; □ Other Deadline Pressures □ limited capacity □unable to perform □ no restriction; □ Other Time Management □ limited capacity □unable to perform □ no restriction; □ Other Attention to Detail □ limited capacity □unable to perform □ no restriction; □ Other Multi-tasking □ limited capacity □unable to perform □ no restriction; □ Other Responsibility/Accountability□ limited capacity □unable to perform □ no restriction; □ Other Problem Solving □ limited capacity □unable to perform □ no restriction; □ Other Exposure to Confrontation □ limited capacity □unable to perform □ no restriction; □ Other Interpersonal Contact □ limited capacity □unable to perform □ no restriction; □ Other ENVIRONMENTAL STIMULI: Exposure to heat/cold □ limited capacity □unable to perform □ no restriction; □ Other Exposure to dust/fumes/odour □ limited capacity □unable to perform □ no restriction; □ Other Exposure to chem...
Sample 1
FUNCTIONAL ABILITIES. 5. Whether you are following a recommended treatment plan. If an absence is suspicious, extensive, or if you are requesting a return to work from a lengthy absence or an accommodation, more medical information is often required. Information such as the nature of the illness, an opinion as to your ability to perform certain tasks, or cognitive or physical limitations may be required. Any medical information released to your Employer requires your consent and all information released must be kept strictly confidential. Do not sign a consent form that allows your Employer to speak directly with your doctor without first speaking to your Union representative. If you are unsure about any requests for medical information from your Employer, contact your Union representative immediately. You should be concerned if your Employer is requesting information such as your diagnosis, treatment details, medications you may be taking, the causes of your condition or forms Editor’s Note: Sadly, this will be Xxxxx’s last article in the UNION magazine. Xxxxx is retiring as of January 10, 2020. He’s not going far, though. He will still be doing some work with us in retirement, but we won’t be graced with his happy demeanor every day in the office anymore. Congratulations on your retirement, Xxxxx! of therapy. This information may be required in some cases, but generally it is considered private and your Employer has no right to require you to provide it. Your Union representative will be able to advise you when such information is required.
Sample 1

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