Healthcare Workload Limit

HEALTHCARE WORKLOAD LIMIT

Patient Information

Patient Name:    Date of Birth:    Gender:

Employer / Work Assignment

Treating Clinician

Clinician Phone:    Clinic Address:

Work Capacity Assessment

Current Work Status:    Full duty    Restricted / Modified duty    Unable to work

Specific Workload Limits and Restrictions

Check all applicable limitations and provide numeric limits where indicated. These restrictions are based on the clinician's assessment of functional capacity and are provided to assist with return-to-work planning. They are not an exhaustive list.

Sedentary: primarily sitting    Standing required
Walking permitted    Ability to alternate sit/stand as needed

Lifting / Carrying limit:   Frequency:

Standing limit per shift:   Walking limit per shift:

Use of dominant upper extremity:

Driving or heavy equipment operation: Restricted   Exposure to heights: Restricted   Hazardous materials: Restricted

Medical History & Current Management

Authorization and Release

I, the undersigned patient, authorize the treating clinician to disclose to my employer or designated employer representative only the medical information reasonably necessary to implement the work restrictions and accommodations described above. This authorization is limited to functional limitations, work capacity, and recommended accommodations and does not permit disclosure of unrelated medical records.

This authorization expires on:

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law.

By checking the box below and signing, I acknowledge that I have read and understand the workload limits and authorize the limited disclosure described above.

I consent to limited disclosure as set forth above.

Administrative Certification and Notices

The information provided on this form is a clinical assessment and recommendation by the treating clinician and is intended to inform workplace decisions regarding accommodations and return to work. Falsification of information on this form may be subject to administrative review and could affect employment or benefits.

The treating clinician should retain a copy of clinical documentation supporting these restrictions in the medical record. Employers may request clarification from the clinician for implementation of accommodations; such requests should be limited to clarifying functional limitations and recommended accommodations.

Signatures

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