Form DCF-F-DWSP2012 "Medical Examination and Capacity" - Wisconsin

What Is Form DCF-F-DWSP2012?

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

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Wisconsin Department of Children and Families;
  • 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 DCF-F-DWSP2012 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Children and Families.

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Download Form DCF-F-DWSP2012 "Medical Examination and Capacity" - Wisconsin

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DEPARTMENT OF CHILDREN AND FAMILIES
WME
Division of Family and Economic Security
MEDICAL EXAMINATION AND CAPACITY
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].
The provision of your Social Security Number (SSN) is mandatory under Wisconsin Statutes 49.145 (2)(k). Your SSN may be verified through
computer matching programs and may be used to monitor compliance with program regulations and program management. Your SSN may be
disclosed to other Federal and State Agencies for official examination. If you do not provide your social security number, your application for
benefits will be denied.
Participant Name
Date of Birth
Social Security Number
/
/
Name of Professional Provider
Professional Title
Office Address
City
State
Zip Code
Dear Health Professional,
The individual named above is an applicant/participant in the Wisconsin Works (W-2) program. The purpose of this
form is to gather information about this individual’s current ability to participate in W-2 activities.
W-2 is a program designed to help individuals become self-sufficient through work and work readiness activities. In
order to assign appropriate activities, it is important for us to have an idea of what tasks and assignments this individual
is capable of. It is also important for us to know about accommodations and modifications that may assist this individual
in participating in work readiness activities.
Activities that can be a part of a W-2 placement include:
job readiness/life skills workshops;
o
education and job skills training;
o
on-the-job work experience;
o
recommended medical treatments; and
o
counseling and physical rehabilitation activities.
o
Please answer the following questions concerning this individual’s medical condition(s):
1. How frequently is the patient scheduled to meet with you?
__________________________________________________________________________________________
Regarding current course of treatment, how long have you been meeting with this patient?
__________________________________________________________________________________________
When is your next scheduled appointment with this patient?
__________________________________________________________________________________________
2. Are you aware of any other health care professionals who are currently treating this person? If yes, please identify provider
name and purpose of treatment:
__________________________________________________________________________________________
3. Diagnosis/Condition: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. Prognosis: (if the patient’s condition is related to pregnancy, please enter the expected date of birth)
__________________________________________________________________________________________
__________________________________________________________________________________________
DCF-F-DWSP2012 (R. 10/2018)
DEPARTMENT OF CHILDREN AND FAMILIES
WME
Division of Family and Economic Security
MEDICAL EXAMINATION AND CAPACITY
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].
The provision of your Social Security Number (SSN) is mandatory under Wisconsin Statutes 49.145 (2)(k). Your SSN may be verified through
computer matching programs and may be used to monitor compliance with program regulations and program management. Your SSN may be
disclosed to other Federal and State Agencies for official examination. If you do not provide your social security number, your application for
benefits will be denied.
Participant Name
Date of Birth
Social Security Number
/
/
Name of Professional Provider
Professional Title
Office Address
City
State
Zip Code
Dear Health Professional,
The individual named above is an applicant/participant in the Wisconsin Works (W-2) program. The purpose of this
form is to gather information about this individual’s current ability to participate in W-2 activities.
W-2 is a program designed to help individuals become self-sufficient through work and work readiness activities. In
order to assign appropriate activities, it is important for us to have an idea of what tasks and assignments this individual
is capable of. It is also important for us to know about accommodations and modifications that may assist this individual
in participating in work readiness activities.
Activities that can be a part of a W-2 placement include:
job readiness/life skills workshops;
o
education and job skills training;
o
on-the-job work experience;
o
recommended medical treatments; and
o
counseling and physical rehabilitation activities.
o
Please answer the following questions concerning this individual’s medical condition(s):
1. How frequently is the patient scheduled to meet with you?
__________________________________________________________________________________________
Regarding current course of treatment, how long have you been meeting with this patient?
__________________________________________________________________________________________
When is your next scheduled appointment with this patient?
__________________________________________________________________________________________
2. Are you aware of any other health care professionals who are currently treating this person? If yes, please identify provider
name and purpose of treatment:
__________________________________________________________________________________________
3. Diagnosis/Condition: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. Prognosis: (if the patient’s condition is related to pregnancy, please enter the expected date of birth)
__________________________________________________________________________________________
__________________________________________________________________________________________
DCF-F-DWSP2012 (R. 10/2018)
5. When did your patient’s symptoms begin (estimate date)?
__________________________________________________________________________________________
Is it likely that your patient’s symptoms will last 6 months or longer?
Yes
No
Is it likely that your patient’s symptoms will last 12 months or longer?
Yes
No
6. What kind of treatment plan is the patient involved in? What is the expected outcome?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If schedule for treatment plan is known, please include below or attach:
__________________________________________________________________________________________
__________________________________________________________________________________________
7. What type of environment or conditions could help this person function most effectively in a variety of daily
activities? __________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
8. This individual may have his/her vocational capacity assessed. What, if any, accommodations should be provided
for the assessment? _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
9. Is the patient attending scheduled appointments?
Yes
No
If no, please explain and list missed appointment dates:
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you attribute the missed appointments to the impairment(s)?
Yes
No
10. Identify any psychological conditions that you are aware of:
Depression
Anxiety
Somatoform disorder
Personality disorder
Psychological factors affecting
Other:______________________________________________
physical condition
11. Physical Capacities
Maximum ability to lift and carry on an occasional basis (no more than 2 hours out of an 8 hour day).
No limitation
100 lbs.
50 lbs.
20 lbs.
10 lbs.
Other ___________________________
Maximum ability to lift and carry on a frequent basis (no more than 6 hours out of an 8 hour day)
No limitation
100 lbs.
50 lbs.
20 lbs.
10 lbs.
Other _____________________
Maximum ability to stand and walk (with normal breaks) during an 8 hour day.
No limitation
no more than 6 hours
no more than 2 hours
Other _____________________
How many city blocks can this individual walk without rest or severe pain? _______________________________
Maximum ability to sit (with normal breaks) during an 8 hour day.
No limitation
no more than 6 hours
no more than 2 hours
Other _____________________
DCF-F-DWSP2012 (R. 10/2018)
2
For questions 12-14 below, “rarely” means 1%-5% of an eight-hour workday; “occasionally” means 6%-33% of an eight-
hour workday; and “frequently” means 34%-66% of an eight-hour workday.
12. How often can this individual perform the following activities?
Activity
Never
Rarely
Occasionally
Frequently
Look down (sustained flexion of neck)
Turn head right or left
Look up
Hold head in static position
Twist
Stoop (bend)
Crouch/squat
Climb ladders
Climb stairs
13. Does this patient have significant limitations with reaching, handling, or fingering?
Yes
No
If yes, please indicate the percentage of time during an 8-hour day that your patient can use hands/fingers/arms
for the following activities:
Activity
Never
Rarely
Occasionally
Frequently
Hand: Grasp, turn twist objects
Right
Left
Fingers: Fine finger manipulation
Right
Left
Arm: Reaching (include overhead)
Right
Left
14. If your patient’s symptoms interfere with performance of simple work task, please estimate the frequency of interference?
Never
Rarely
Occasionally
Frequently
15. What is your assessment of this individual’s ability to communicate and see?
___________________________________________________________________________________________
___________________________________________________________________________________________
16. Is your patient making positive progress?
Yes
No
Please describe the progress or lack of progress.
__________________________________________________________________________________________
__________________________________________________________________________________________
17. Are the patient’s impairments likely to produce ‘bad’ days?
Yes
No
If yes, on the average, how often do you anticipate that your patient’s impairments would become acute so that
the patient would be absent from work and/or other W-2 activities?
Once per month or less
Over twice per month
About twice per month
More than 3 times per month
18. Does this person’s medication(s) or treatment cause side affects that impact his/her ability to participate in a
work/education environment (e.g., drowsiness, dizziness, nausea, etc.)?
Yes
No
If “Yes” specify: _____________________________________________________________________________
DCF-F-DWSP2012 (R. 10/2018)
3
19. Does this person require any adaptive devices or other accommodations to help him/her function effectively in a
work/education environment (e.g., assistive device for ambulation, need to alternate positions frequently, limits on
pushing and pulling, operating hand or foot controls, accommodations for bending and stooping, part-time or flexible work
schedule, etc.)?
Yes
No
Unknown
If “Yes” describe what is needed:
__________________________________________________________________________________________
20. Identify any of the following that your patient is likely to experience:
Low tolerance for frustration
Difficulty maintaining activities of daily living
Difficulty communicating his/her needs
Difficulty with decision making
Difficulty following instructions
Difficulty following through on agreed actions
Inability to work with children
Panic attacks
Difficulty working around other people
Difficulty with reality interpretation
Difficulty controlling anger appropriately
Difficulty being in unfamiliar environment
Socially inappropriate responses to situations
Difficulty with impulse control
Seizures
Difficulty maintaining concentration
Difficulty engaging in complex tasks that
Other: ______________________________
requirement judgment
21. Please recommend any other activities and services not included in your treatment plan that may help this individual further
address his/her mental health impairment:
Assessment (please specify type)
Treatment and/or counseling (please specify)
______________________________
___________________________________
Advocacy for Social Security Income/Disability
Other _______________________________
22. Additional Recommendations or Restrictions: ______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
23. Considering this patient’s condition(s) and limitation(s) please indicate below what activities related to work and training you
would recommend?
work/work experience activities
job skills training
adult basic education/literacy
supported job search activities
job readiness/life skills workshops
other
If no recommendations, please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
24. Estimate the number of hours a day (5 days a week) this individual can participate in work/work readiness activities within
these recommendations :________________________________________________________________
25. If you have indicated anywhere on this form that this patient is unable to participate in W-2 activities, please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
26. Given your patient’s current medical condition(s), please specify a date when the recommendations that you have
provided should be reviewed:__________________________________________________________________
DCF-F-DWSP2012 (R. 10/2018)
4
Name of Professional Provider
Title
Telephone Number
Signature of Professional Provider
Date Signed
Return completed form to:
Name of Agency Representative
Address
Date Sent
City
State
Zip Code
Telephone Number
Fax Number
DCF-F-DWSP2012 (R. 10/2018)
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