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Fitness for Work Assessment Checklist

A fitness for work assessment checklist includes questions about physical and mental health, work environment, and job demands. It helps employers evaluate an employee’s ability to safely and effectively perform a job.

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Fitness For Work Assessment Form
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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Ensure Employee Wellbeing with a Comprehensive Fitness for Work Assessment Checklist


A fitness for-work assessment checklist is a tool used to measure an employee’s capacity to perform their job. It is a valuable tool used by employers to ensure that their employees are physically and mentally fit to work. The checklist typically consists of a questionnaire or other form of survey that asks the employees questions about their physical and mental well-being. It may include questions about current health conditions, lifestyle habits, past medical history, and any relevant medications.


The purpose of this assessment is to determine if an employee is able to safely and effectively carry out the duties of their job. It also allows employers to identify any health risks that may be present in the workplace. The results of the assessment are then used to determine if any accommodations need to be made to ensure the employee can perform their job safely. For instance, they may need to be provided with ergonomic furniture, special equipment, or additional breaks. Fitness for work assessments is an important part of any employer’s health and safety program. They help employers ensure that their employees remain healthy, safe, and productive.

Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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