Functional Capacity/Disability Evaluation Report

Report Title: Functional Capacity/Disability Evaluation Report

Report Date: [Date report finalized]

Evaluation Date(s): [Date(s) of evaluation]

Examinee: [Full name, DOB]

Claim/Case ID: [Claim number; date of injury if applicable]

Referring Party: [Name/organization and role]

Examiner: [Name, credentials, license number]

Examiner Role: [Treating clinician / Independent examiner]

(Throughout the report, label each piece of information with its source: [self-reported], [observed], [measured], or [from records (source, date)]. Use objective, behavior-based language. Do not infer intent or motive.)

Referral Context and Scope

[Decision need prompting evaluation] (State why the evaluation was requested: return-to-work capacity, disability certification support, fitness for essential job demands, accommodation planning.)

• [Specific referral questions to be answered] (List each question verbatim if provided; if vague, document the operational interpretation used.)

[Scope boundaries] (State what this evaluation addresses and what it does not determine, such as legal disability adjudication or causation unless explicitly requested.)

Consent and Disclosure

[Nature of relationship: treating / limited-purpose independent evaluation; requesting party; report recipients]

[Confirmation that examinee was informed of purpose, intended recipients, and confidentiality limits]

• [Intended report recipients]

(Omit this section for purely internal clinical contexts.)

Records Reviewed

• [Document type; date range; source]
• [Imaging/diagnostic reports; date; source]
• [Therapy/rehabilitation notes; date range; source]
• [Job description/essential functions; date; source]
• [Prior FCEs or capacity evaluations; date; source]
• [Collateral information from employer/treating clinician; date; source]

Requested but not provided: [Key records not received and impact on interpretation]

Relevant History

Condition/injury timeline: [Onset/mechanism, course, major interventions, treatment response] (Include only details that affect functional interpretation.)

Current symptoms affecting function: [Pain, fatigue, weakness, sensory changes; variability; triggers; relieving factors] [self-reported]

Medications on day of testing: [Medication names, timing, potential impact on performance]

Self-reported functional status: [ADLs, driving, household activities, community participation, sleep] [self-reported]

Work history and job demands: [Job title; essential tasks; physical demands (lifting/carrying/push-pull/postures); schedule; cognitive/safety-critical duties] (Note any discrepancies between sources.)

Comorbidities materially affecting capacity: [Cardiopulmonary disease, neuropathy, metabolic conditions, mental health conditions]

Pre-Test Screening and Safety

• Medical screening: [Contraindications/precautions identified]
• Baseline vitals: [BP, HR, SpO2] [measured] (If not measured, state why.)
• Fall risk/mobility: [Assessment findings; assistive devices] [observed]
• Stop criteria used: [Unsafe biomechanics / symptom escalation / vital sign thresholds / neurologic red flags]
• Safety measures: [Spotter, gait belt, assistive devices, protective equipment]
• Adverse events: [Description or "None"]

Evaluation Methods

Protocol: [FCE protocol name or in-house approach; single-day / multi-day; total duration]

Test domains covered: [Material handling; positional tolerances; upper extremity/hand function; endurance; task simulation; cognitive demands]

Equipment and calibration: [Dynamometers, force gauges, ergometers; calibration status]

Procedures: [Warm-up instructions; number of trials; rest periods; standardized instructions]

Scoring approach: [Maximum safe / psychophysical / biomechanical / cardiovascular-limited endpoints; advancement/termination criteria]

Personnel: [Administered by; interpreted/authored by] (Clarify roles if different.)

Objective Clinical Findings

• Gait/transfers/balance: [Description; laterality; assistive device] [observed]
• Neuromusculoskeletal: [Focused ROM, gross strength, sensation with units and laterality] [measured] (Include only findings relevant to function.)
• Functional movement quality: [Compensations, guarding, strategy selection, movement control] [observed]

Functional Testing Results

Material Handling Capacity

Activity	Weight/Force	Frequency	Limiting Factor
Lifting: Floor to Waist	[Value with units]	[Occasional / Frequent / Constant]	[Pain / Strength / Balance-Safety / Biomechanical form / Cardiovascular / Protocol stop criteria]
Lifting: Waist to Shoulder	[Value with units]	[Occasional / Frequent / Constant]	[Limiting factor]
Lifting: Shoulder to Overhead	[Value with units]	[Occasional / Frequent / Constant]	[Limiting factor]
Carrying	[Value with units; distance]	[Occasional / Frequent / Constant]	[Limiting factor]
Push	[Initial/sustained force with units]	[Occasional / Frequent / Constant]	[Limiting factor]
Pull	[Initial/sustained force with units]	[Occasional / Frequent / Constant]	[Limiting factor]

Frequency definitions used: [State standard and thresholds, e.g., DOT: occasional = up to 1/3 of shift; frequent = 1/3–2/3; constant = >2/3]

(If any activity was not tested, state "Not tested" with reason: not requested, contraindicated, insufficient job data, or safety concern.)

Positional Tolerances

Position	Duration/Tolerance	Notes
Sitting	[Max continuous; total per shift]	[Position change needs; observed limitations]
Standing	[Max continuous; total per shift]	[Notes]
Walking	[Distance/time tolerance]	[Assistive device; pace; terrain]
Kneeling	[Tolerance]	[Notes]
Crouching	[Tolerance]	[Notes]
Stooping	[Tolerance]	[Notes]
Climbing	[Ladders/stairs; tolerance]	[Handrail use; safety concerns]
Crawling	[Tolerance]	[Notes]
Overhead Reaching	[Tolerance and frequency]	[Laterality; compensation patterns]

(If not tested, state "Not tested" with reason.)

Upper Extremity and Hand Function

Grip and pinch strength: [Device; hand dominance; number of trials; values with units; coefficient of variation] [measured]

Fine motor/dexterity: [Test name(s); time/scores; hand(s) tested] [measured] (State "Not tested" with reason if not performed.)

Reaching/handling/fingering tolerances: [Repetitive task tolerances; observed quality; laterality] [observed]

Endurance/Work Tolerance

Test Name	Performance	Physiologic Response	Symptom Response
[6MWT / cycle ergometry / step test / other]	[Distance/time/workload with units]	[HR, BP, SpO2, RPE]	[Symptoms and timing]

8-hour extrapolation: [Logic, assumptions, and limitations of extrapolation] (Include only if performed.)

(If not tested, state "Not tested" with reason.)

Task Simulation

[Job-specific simulation description: tasks, loads, durations, environmental conditions]

[Observations: movement quality, safety, symptom response] [observed]

[Match to actual job demands: exact match / approximation with gaps noted]

(If no simulation performed, state "Not tested" with reason.)

Effort, Consistency, and Validity

• Consistency measures used: [Repeated trials, comparable tasks, physiologic response vs. reported exertion, movement quality vs. measured output]
• Observed variability: [Behavior-based description; comparison to expected test-retest variation]
• Effort characterization: [If self-limited behavior observed despite stable mechanics/vitals, state results may represent minimum demonstrated capacity rather than maximum safe capacity]
• Safety limitations: [If testing endpoints were safety-limited, state higher loads were not attempted]

Interpretability: [Valid for minimum demonstrated capacity / Valid for safe maximum within protocol constraints / Limited validity with explanation]

Functional Capacity Summary

• Sitting: [Max continuous and total shift tolerance; position change needs]
• Standing: [Max continuous and total shift tolerance]
• Walking: [Distance/time; terrain tolerance; assistive device]
• Lifting/Carrying: [Weights by level and frequency; carry distances]
• Push/Pull: [Forces and frequencies]
• Postural tolerances: [Stooping, kneeling, crouching, climbing, crawling]
• Manipulative tolerances: [Reaching including overhead, handling, fingering; laterality]

Exertional category: [Sedentary / Light / Medium / Heavy / Very Heavy] (Include only if required by stakeholders. State standard and definitions used.)

Job match analysis: [Comparison of each essential job demand to measured capacity; meets/does not meet; accommodations needed] (If job demands unknown, state job-match conclusions cannot be made.)

Limitations and Restrictions

Functional limitations: [What the examinee cannot safely perform or sustain under test conditions; quantify with weights, forces, durations, frequencies, distances]

Restrictions: [Examiner recommendations: specific limits with quantification; time-limited with anticipated duration and re-evaluation plan; safety justification tied to objective findings]

Accommodation recommendations: [Sit/stand option; lift assists; task rotation; ergonomic modifications; schedule adjustments] (Include if applicable.)

Opinion and Rationale

(Answer only the questions specified in the referral. Provide objective findings supporting each opinion, record-based support, and reasoning linking findings to conclusions. Acknowledge conflicting evidence and explain weighting.)

• Question: [Restated referral question]
• Opinion: [Direct answer: full duty / modified duty with specifics / off work; or fitness conclusion]
• Rationale: [Objective findings, records, and reasoning supporting opinion; conflicting evidence addressed]

(Repeat structure for each referral question.)

Impairment rating: [MMI status; rating method/edition; rating details] (Include only if requested and examinee has reached MMI.)

Unanswerable questions: [What is missing; why it prevents conclusion; what would resolve it] (Include if any questions cannot be answered.)

Recommendations

• [Rehabilitation: work conditioning/hardening; PT/OT focus areas]
• [Worksite/ergonomic modifications]
• [Further diagnostics or specialist referral]
• [Re-evaluation timing, especially if restrictions are time-limited]

Evaluation Limitations

• [Snapshot nature of testing vs. longitudinal work performance]
• [Safety-limited or pain-limited endpoints and implications]
• [Impact of missing job descriptions or records]
• [External validity limits: single-day vs. multi-day tolerance; testing environment vs. actual workplace]

Signature

Examiner Signature: ________________________________

Printed Name: [Name]

Credentials: [Credentials]

License Number: [License number and jurisdiction]

Date Signed: [Date]

Attachments: [Raw data sheets, dynamometer printouts, normative tables, job description excerpts]