Fit for Work Assessment Form
Use this form to assess work readiness, any limitations, and needed adjustments. Keep responses accurate and concise.
Worker Details
Respondent Name
*
Job Title / Role
*
Department or Team
*
Preferred Contact Email
*
example@example.com
Work Capability Assessment
Current work status
*
Fit for full duties
Fit with restrictions
Temporarily unfit
Requires further review
Capability assessment
*
Rows
Unable
Limited
Moderate
Good
Excellent
Stamina
1
2
3
4
5
Mobility
6
7
8
9
10
Concentration
11
12
13
14
15
Ability to perform core duties
16
17
18
19
20
Restrictions, Adjustments, and Follow-up
Work restrictions or adjustments needed
Expected return-to-work or review date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor or assessor notes
Overall fit-for-work assessment
*
1
2
3
4
5
Submit
Should be Empty: