Form ADM4317 "Work Capacity Form" - Ohio

What Is Form ADM4317?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2001;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADM4317 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4317 "Work Capacity Form" - Ohio

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DEPARTMENT OF ADMINISTRATIVE SERVICES
Human Resources Division
WORK CAPACITY FORM
Benefits Administration Services
30 East Broad Street, 28th Floor
Columbus, Ohio 43215
Name: ______________________________________________
Date of Birth:___________________
Job Title: ____________________________________________
Claim No.: ____________________
Dear Doctor:
Many State of Ohio agencies have early return to work programs or are willing to make temporary work assignment
adjustments to enable a State of Ohio employee to return to work while they complete their recovery. Please help us in
our efforts to return our employees to work by completing the following questionnaire and returning to us by fax at
(614) 466-0831. Thank you for your assistance.
1. What job duties is patient unable to perform?
2. In an 8-hour workday, person can:
(Circle full capacity for each activity)
TOTAL (hours)
Sit
0
1
2
3
4
5
6
7
8
Stand
0
1
2
3
4
5
6
7
8
Walk
0
1
2
3
4
5
6
7
8
3. Person can lift and carry:
Never
Occasionally
Frequently
Constantly
( 1% - 33% )
( 34%- 66% )
( 67%-100 )
Up to 10 lbs.
_____
_________
________
________
11-20 lbs.
_____
_________
________
________
21-50 lbs.
_____
_________
________
________
Over 50 lbs.
_____
_________
________
________
4. Person can push/pull:
Never
Occasionally
Frequently
Constantly
( 1% - 33% )
( 34%- 66% )
( 67%-100 )
Up to 10 lbs.
_____
_________
________
________
11-20 lbs.
_____
_________
________
________
21-50 lbs.
_____
_________
________
________
51-100 lbs.
_____
_________
________
________
Over 100 lbs.
_____
_________
________
________
5. Person can do repetitive movements as in keyboard operation:
Right Hand/Arm
Right Foot/Leg
Left Hand/Arm
Left Foot/Leg
Yes
No
Yes
No
Yes
No
Yes
No
6. Person can:
Never
Occasionally
Frequently
Constantly
( 1% - 33% )
( 34%- 66% )
( 67%-100 )
Climb
_____
_________
_________
_________
Balance
_____
_________
_________
_________
Stoop
_____
_________
_________
_________
Kneel
_____
_________
_________
_________
Crawl
_____
_________
_________
_________
Reach/Handle
_____
_________
_________
_________
(over)
ADM4317 (Rev. 12/2001)
DEPARTMENT OF ADMINISTRATIVE SERVICES
Human Resources Division
WORK CAPACITY FORM
Benefits Administration Services
30 East Broad Street, 28th Floor
Columbus, Ohio 43215
Name: ______________________________________________
Date of Birth:___________________
Job Title: ____________________________________________
Claim No.: ____________________
Dear Doctor:
Many State of Ohio agencies have early return to work programs or are willing to make temporary work assignment
adjustments to enable a State of Ohio employee to return to work while they complete their recovery. Please help us in
our efforts to return our employees to work by completing the following questionnaire and returning to us by fax at
(614) 466-0831. Thank you for your assistance.
1. What job duties is patient unable to perform?
2. In an 8-hour workday, person can:
(Circle full capacity for each activity)
TOTAL (hours)
Sit
0
1
2
3
4
5
6
7
8
Stand
0
1
2
3
4
5
6
7
8
Walk
0
1
2
3
4
5
6
7
8
3. Person can lift and carry:
Never
Occasionally
Frequently
Constantly
( 1% - 33% )
( 34%- 66% )
( 67%-100 )
Up to 10 lbs.
_____
_________
________
________
11-20 lbs.
_____
_________
________
________
21-50 lbs.
_____
_________
________
________
Over 50 lbs.
_____
_________
________
________
4. Person can push/pull:
Never
Occasionally
Frequently
Constantly
( 1% - 33% )
( 34%- 66% )
( 67%-100 )
Up to 10 lbs.
_____
_________
________
________
11-20 lbs.
_____
_________
________
________
21-50 lbs.
_____
_________
________
________
51-100 lbs.
_____
_________
________
________
Over 100 lbs.
_____
_________
________
________
5. Person can do repetitive movements as in keyboard operation:
Right Hand/Arm
Right Foot/Leg
Left Hand/Arm
Left Foot/Leg
Yes
No
Yes
No
Yes
No
Yes
No
6. Person can:
Never
Occasionally
Frequently
Constantly
( 1% - 33% )
( 34%- 66% )
( 67%-100 )
Climb
_____
_________
_________
_________
Balance
_____
_________
_________
_________
Stoop
_____
_________
_________
_________
Kneel
_____
_________
_________
_________
Crawl
_____
_________
_________
_________
Reach/Handle
_____
_________
_________
_________
(over)
ADM4317 (Rev. 12/2001)
7. Any difficulties involving:
None
Mild
Moderate
Severe
Talking
_____
_____
_____
_____
Hearing
_____
_____
_____
_____
Tasting/Smelling/Vision
_____
_____
_____
_____
8. Any restrictions of activities
None
Mild
Moderate
Severe
involving:
Exposure to cold/heat
_____
_____
_____
_____
Noise
_____
_____
_____
_____
Exposure to Fumes
_____
_____
_____
_____
Driving
_____
_____
_____
_____
9. Is this person involved with treatment and/or medication that might affect his/her ability to work:
No
Yes, Describe: __________________________________________________________
__________________________________________________________________________________
10. Patient’s condition prevents them from working:
Temporarily ______
For longer than 12 months ______
Permanently ______
11. If disability is temporary, patient’s estimated date of release to return to work:
With restrictions listed above
Mo. ______
Day ______
Yr. ______
For regular occupation without restrictions
Mo. ______
Day ______
Yr. ______
On a part-time basis
Mo. ______
Day ______
Yr. ______
Hours per day ______
days per week ______
# of weeks ______
Additional Comments: _________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Name(treatment provider) Please print
Specialty
Fed ID#
Street address, City, State and Zip
Telephone (area code)
Fax (area code)
E-mail address
ADM4317 (Rev. 12/2001)
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