Fit for Work Assessment Form
Evaluate and document an individual's fitness to safely perform their job duties.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Job Title / Department
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate if you are currently experiencing any of the following symptoms or conditions:
*
Fever or chills
Cough or sore throat
Shortness of breath
Musculoskeletal pain or injury
Fatigue or dizziness
Other (please specify)
Relevant Medical History (e.g., chronic conditions, recent surgeries, allergies)
Assessment of Functional Abilities
*
Rows
No Limitation
Mild Limitation
Moderate Limitation
Severe Limitation
Standing/walking
1
2
3
4
Lifting/carrying
5
6
7
8
Bending/twisting
9
10
11
12
Vision/hearing
13
14
15
16
Concentration/mental focus
17
18
19
20
Operating machinery
21
22
23
24
Are there any work restrictions or accommodations required?
*
No restrictions needed
Temporary restrictions (please specify)
Permanent restrictions (please specify)
Additional Comments or Recommendations
Assessor Name (Person conducting the assessment)
*
First Name
Last Name
Assessor's Position or Title
*
Assessor Email Address
*
example@example.com
Employee Signature
*
Submit Assessment
Submit Assessment
Should be Empty: