This form is for employers to gain information about an injured employee’s functional abilities after a work-related injury. This information can be used to plan a safe and timely return to work for the employee.

To use this form:

1. Download the form and give it to your employee who has experienced an injury at work.
2. Ask the employee to take the form to their health care provider and then return the completed form to you.
3. Use the information in the form to help identify suitable work for them.

To learn more about helping an injured employee return to work, visit worksafebc.com/returntowork.