Incapacity For Work Questionnaire

June 9, 2011

Name :              _________________________________________________________________

Employee Code:  ___________________________________________________________

Name of the person fulfilling this form stating reason and relationship:

______________________________________________________________________________________

Your telephone no:              ________________   _________________        __________________

Daytime         Office                   Mobile

  1. Kindly tell us about disability or illness

________________________

  1. Are you being treated by a doctor? Are you receiving any care or help from others? Any treatment from hospitals? If yes please furnish contact and details.

___________________________.

  1. Do you think that your present condition is attributed to drug, alcohol misuse or misuse of other substance?

_____________________________

  1. Are you able to walk:-
    1. Ground level without difficulty?
    2. Ground level up to 200 yards, and then need to stop
    3. Two or three staircases up or down
  1. Are you able to sit and stand? If not please brief us about your difficulties.

________________________________

  1. Are you able to bend and kneel without difficulty? If not please brief us about your difficulties.

______________________________.

  1. Are you able to use your arms to pick up objects at same level? Are you able to reach top or bottom shelves? If not please brief us about your difficulties.

__________________________

  1. Any problems in speech, sight or hearing? Describe briefly.

_______________________________

  1. Any problems in keeping awake and conscious?

__________________________

  1. Any problem in focusing or concentrating?

_______________________________

  1. Any problem in socializing, group activity?

_____________________________.

  1. Any other problems?

__________________________

Download Sample Incapacity For Work Questionnaire in Word Format

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