Functional Abilities Form Mental Illness, PTSD and/or Mild Traumatic Brain Injury MTBI

Transcription

1 Functional Abilities Form Mental Illness, PTSD and/or Mild Traumatic Brain Injury MTBI Instructions: Please complete ALL sections of this form. Thank you Claim No. A. Section A to be completed by the employer and/or worker Workers last name: Workers first name: Telephone Address City/Town Province Postal Code Date of Birth (dd/mm/yyyy) Employer s Name Date of Accident / Incident (dd/mm/yyyy) Full Address Employer Telephone City/Town Prov. Postal Code Employer Fax No. 1. Type of job at the time of accident (where available, please attach description of job activities) 2. Area(s) of injury(ies) / illness(es) 3. Brief Description of RTW Offer: 4. Date of current Offer of Modified Duties: 5. Employer contact name Position B. Worker s Signature By signing below, I am authorizing any health professional who treats me to provide me, my employer and the Workplace Safety and Insurance (WSIB) with information about my functional abilities on the this form created by my employer. Signature: Date: (dd/mm/yyyy) Worker s Last Name First Name Claim No. Functional Abilities for RTW with PTSD or MTBI (v.1 Oct 5, 2016) Page 1 of 6

2 C. Health Professional s Information Health Professional Designation Family Doctor Treating Psychologist Treating Psychiatrist Other D. The following information should be completed by the Health Professional to identify the patient s overall abilities and restrictions. 1. Date of Assessment 2. Please check one: (dd/mm/yyyy) Patient is capable of returning to work with no restrictions Patient is capable of returning to work with restrictions. Complete Sections E Patient is unable to return to work at this time. Complete Section I on page 6 of this document E. Restrictions Please indicate RESTRICTIONS that apply. Include additional details in section Social Supervising others Working with crisis or emergency situations Working in isolation Influencing others Working closely with the public, clients, or others (e.g. colleagues, supervisor) Teamwork Working in high environmental, noise, stimulation areas Seeking/responding to feedback /constructive criticism Exposure to emotional or confrontational patients/customers/ 2. Hours On call Following a schedule, mainlining attendance/ punctuality Prolonged work days, overtime Shift work, rotating Frequent deadlines Occasional deadlines Maintaining stamina / pace of work Variety of tasks Monotony First responder emergency situations Functional Abilities for RTW with PTSD or MTBI (v.1 Oct 5, 2016) Page 2 of 6

3 E. 2. Hours Continued Travel: Frequency: Mode of transportation: (Does the employee require employer assistance with travel?) Time of day 3. Physical Work Environment Indoors Outdoors Closed office Open office (i.e. cubicle) Exposure to weather Exposure to noise/distracting stimuli Extreme Heat or Cold Moisture (wet/humid) Dryness Fumes/Vapours/Dust Vibration Wildlife 4. Potential Hazards Electric Shock Radiation ionizing, nonionizing Sharp Objects Sustained posture Intermittent noise Continuous noise Moving Mechanical Parts Awkward posture Physical violence (e.g agitated patients) Infectious exposure Waste handling Repetitive movements Handling of firearms Biological / chemical Handling heavy contaminants machinery or equipment 5. In relation to PTSD (which of the following if any, should be considered / integrated into the RTW plan?) Not applicable Physiological reactions to triggers Sleep disturbances Exposure to unfamiliar Flashbacks stimuli Irritable behavior Hyper vigilance Exaggerated startle response Avoidance of triggers (go to Section 9) Functional Abilities for RTW with PTSD or MTBI (v.1 Oct 5, 2016) Page 3 of 6

4 6. In relation to a Mild Traumatic Brain Injury or PTSD: Not Applicable Difficulty with concentration Continuous alertness Ability to drive Balance difficulties Fatigue Needs a break every: Relieved by: Relieved by: Light sensitivity Needs naps every Short term memory loss Sound Sensitivity Needs sunglasses hours Assistance required: Relieved by: Yes No Yes No e.g.: Recording Device Day Planner Note Pads Quiet surroundings Noise cancelling headphones Other Other 7. Cognitive / Mental Demands (which of the following should be considered / integrated into the RTW plan?) Self-supervision / autonomy Attention to detail Attaining precise limits / standards Continuous alertness, sustained concentration/focus Retention of information Working under specific instructions Multitasking Organizational ability, time management Problem solving, decision making Initiative Adaptability Analytical thinking Sound judgement Effective written communication Handling firearms Handling heavy machinery or equipment 8. Additional Comments, Restrictions or Considerations: Functional Abilities for RTW with PTSD or MTBI (v.1 Oct 5, 2016) Page 4 of 6

5 9. Aggravating or triggering stimuli to be avoided: 10. Would the worker benefit from a one on one occupational therapist on a temporary basis to facilitate a return to work? F. Sources of Collateral Information List all the sources of information that you have reviewed regarding the workplace Incident/Accident Source Indicate if used Please provide details and itemize reviewed sources below WSIB Patient Police Employer Medical MOL Pictures Video Other G. List all the sources of information on Patient HX Source Indicate if used Please provide details and itemize reviewed sources below Patient WSIB Family Matters Independent Medical Assessments Treating FMD Treating Psychologist or Psychiatrist Functional Abilities for RTW with PTSD or MTBI (v.1 Oct 5, 2016) Page 5 of 6

6 H. Stay at Work Better at Work Principles 1. What other changes would you recommend to facilitate an earlier and safer RTW for this worker? 2. From the date of this assessment, the above will apply for approximately: 3. Have you reviewed the RTW offer attached to this FAF? 1-2 Days 3-7 Days 8-14 Days 14+ Days Yes No 4. Recommendations for work hours and start date: Regular full-time hours Reduced Hours Graduated Return to Work 5. Start Date (dd/mm/yyyy) Specific hours per day: Specific days per week: I. If worker totally occupationally disabled If you have determined that the worker is 100% occupationally disabled at this time, please provide objective, detailed clinical reasons for this assessment: I hereby declare that the information being submitted in this form is true and complete. Health Professional s Signature Telephone Date (dd/mm/yyyy) I have provided this completed Functional Abilities Form to: Worker and/or Employer Functional Abilities for RTW with PTSD or MTBI (v.1 Oct 5, 2016) Page 6 of 6