Functional Abilities Form Template – Canada

The Functional Abilities Form Template – Canada is provided in multiple formats, including PDF, Word, and Google Docs. These templates are conveniently editable and printable, crafted to suit your requirements effortlessly.

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Functional Abilities Form Template – Canada

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1. Client Information



2. Referring Healthcare Provider



3. Functional Abilities Assessment Summary

4. Specific Functional Abilities

5. Limitations and Restrictions

6. Recommendations for Accommodations

7. Follow-up Plan

8. Signature of Healthcare Provider

9. Date of Assessment

10. Client Acknowledgment

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Examples

Functional Abilities Form Template – Canada (1)
Employee Information:
[Employee’s Name]
[Employee’s ID]
[Employee’s Address]
[Employee’s Phone]
[Employee’s Email]
Employer Information:
[Employer’s Name]
[Employer’s ID]
[Employer’s Address]
[Employer’s Phone]
[Employer’s Email]
Introduction:
This Functional Abilities Form (“Form”) is designed to assess the employee’s current abilities and limitations, ensuring a conducive work environment that matches their capabilities, effective from [Start Date].
Section 1: Job Details
Position Title: [Job Title]
Department: [Department Name]
Supervisor: [Supervisor’s Name]
Start Date: [Start Date]
Section 2: Functional Abilities
The employee is capable of performing the following activities:
– [List of Physical Activities]
– [List of Cognitive Activities]
– [List of Environmental Requirements]
Section 3: Limitations
The employee has the following limitations:
– [List of Limitations]
– [Description of Impact on Job Duties]
Section 4: Recommendations
To facilitate the employee’s return to work, it is recommended to consider:
– [Adjustments to Work Environment]
– [Modified Job Duties]
– [Flexible Work Hours]
Section 5: Medical Professional’s Input
Name of Medical Professional: [Name]
Contact Information: [Contact Details]
Date of Evaluation: [Evaluation Date]
Comments: [Any Additional Comments]
Signed in [City], [Date].
Sincerely,
[Employee’s Signature]
[Employee’s Name]
[Supervisor’s Signature]
[Supervisor’s Name]
Functional Abilities Form Template – Canada (2)
Employee Information:
[Employee’s Name]
[Employee’s ID]
[Employee’s Address]
[Employee’s Phone]
[Employee’s Email]
Employer Information:
[Employer’s Name]
[Employer’s ID]
[Employer’s Address]
[Employer’s Phone]
[Employer’s Email]
Introduction:
This Form aims to document the employee’s functional abilities following any medical condition, ensuring their responsibilities align with their capabilities, effective from [Start Date].
Section 1: Current Job Overview
Position Title: [Job Title]
Department: [Department Name]
Reporting Manager: [Reporting Manager’s Name]
Date of Last Review: [Last Review Date]
Section 2: Abilities Assessment
The employee is able to perform:
– [Physical Tasks, e.g., lifting, sitting, standing]
– [Cognitive Tasks, e.g., decision-making, concentration]
– [Environmental Tasks, e.g., exposure to certain conditions]
Section 3: Identified Restrictions
The following restrictions have been identified:
– [Describe Restrictions]
– [How these affect their job duties]
Section 4: Suggested Accommodations
The following accommodations are suggested:
– [Ergonomic Adjustments]
– [Changes in Equipment]
– [Workplace Modifications]
Section 5: Professional Recommendations
Provider Name: [Medical Provider’s Name]
Contact Information: [Contact Information]
Evaluation Date: [Evaluation Date]
Remarks: [Additional Remarks]
Signed in [City], [Date].
Sincerely,
[Employee’s Signature]
[Employee’s Name]
[Manager’s Signature]
[Manager’s Name]

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Functional Abilities Form Template - Canada