Functional Capacity Evaluation

[YOUR COMPANY NAME]

Name
Evaluation Date
Evaluator Name

Introduction:

This Functional Capacity Evaluation (FCE) is designed to assess an individual's readiness to return to work following an injury or illness. The evaluation aims to provide a comprehensive understanding of the individual's physical and cognitive abilities, as well as any limitations that may impact their ability to perform essential job tasks safely and effectively.

Background:

Returning to work after an injury or illness requires careful consideration of the individual's functional abilities to ensure a safe and successful transition. This evaluation is essential for employers, healthcare providers, and rehabilitation professionals to determine appropriate accommodations, develop return-to-work plans, and support the individual in resuming work activities.

Evaluation Criteria:

• Physical Strength and Endurance: Evaluate the individual's ability to perform physical tasks such as lifting, carrying, pushing, and pulling.

• Range of Motion: Assess the individual's flexibility and joint mobility, particularly in areas relevant to their job duties.

• Balance and Coordination: Determine the individual's ability to maintain balance and coordination while performing various work-related tasks.

• Functional Mobility: Evaluate the individual's ability to move safely and efficiently in different environments, including walking, climbing stairs, and navigating obstacles.

• Manual Dexterity: Assess fine motor skills and hand-eye coordination necessary for tasks such as typing, writing, and operating equipment.

• Cognitive Functioning: Evaluate attention, memory, problem-solving, and other cognitive abilities essential for job performance.

• Pain Management: Assess the individual's ability to manage pain effectively during work activities and identify any limitations related to pain.

• Work Simulation: Provide opportunities for the individual to perform tasks similar to those required in their job role to assess readiness and identify potential challenges.

Evaluation Table:

Criteria	Assessment	Rating (1-5)
Physical Strength and Endurance	Used manual muscle testing and lifting tasks. Assessed endurance with carrying weights.
Range of Motion	Conducted goniometry measurements and functional movement assessments.
Balance and Coordination	Administered balance tests and coordination exercises.
Functional Mobility	Observed walking gait and ability to navigate stairs.
Manual Dexterity	Assessed grip strength and fine motor skills.
Cognitive Functioning	Conducted cognitive tests and problem-solving tasks.
Pain Management	Used pain scales and identified pain triggers.
Work Simulation	Simulated job-specific tasks and evaluated safety awareness.

Rating Scale:

1: Severe limitation, unable to perform tasks.

2: Significant limitation, requires substantial assistance or accommodation.

3: Moderate limitation, able to perform tasks with some difficulty.

4: Mild limitation, able to perform tasks with minimal difficulty.

5: No limitations, able to perform tasks without difficulty.

Additional Comments and Notes

Comments and Notes

Evaluation Templates @ Template.net