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Fitness for Work Assessment Checklist

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Fitness for Work Assessment Checklist

General

Patient Name

Doctor's/ Therapist's Name

Consider s/he has the following medical condition:

Fitness for Work

S/he is/will be:

Fit to carry out normal duties commencing on (date)

Partially fit and capable of performing selected duties (details below) from (date)

from (date)

to (date)

Currently unfit for any work, but maybe able to return to work within ______ days/weeks (a further Fitness for Work Checklist will be sent closer to this date).

Recommended Work Hours

Usual work hours

Reduced work hours _ hours per day/ _ days per week.

Selected duties may include:

Sitting (including frequent breaks)

Standing

Walking

Kneeling

Bending

Crouching/squatting

Climbing stairs

Using step-stool at times

Computer work (including frequent breaks)

Driving - automatic vehicle

Driving - manual vehicle

Mopping or sweeping

Tools/equipment using vibration

Reaching to waist/chest height

Reaching to head height

Reaching below waist to ground level

Lifting/carrying using both hands up to __ kg

Lifting/carrying using right hand up to __ kg

Lifting/carrying using left hand up to __ kg

Pushing/pulling trolleys

Other recommendations:

Confirmation

Name of doctor/registred therapist

Signature

Date

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