Healthcare Worker Service Capacity Assessment Form
Assess a healthcare worker’s current service capacity, availability, workload limits, and support needs.
Worker Profile and Role
Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Department / Unit
Facility / Organization
*
Employment Status
*
Please Select
Full-time
Part-time
Contract
Temporary
Locum
Volunteer
Other
Primary Service Area
*
Please Select
Inpatient
Outpatient
Emergency
Primary Care
Community Health
Laboratory
Pharmacy
Administration
Other
Service Capacity Assessment
Current workload level
*
Very light
1
2
3
4
5
6
7
8
9
Overloaded
10
1 is Very light, 10 is Overloaded
Ability to take additional patients/clients
*
Not able at all
1
2
3
4
5
6
7
8
9
Fully able
10
1 is Not able at all, 10 is Fully able
Energy and burnout impact
*
Severely drained
1
2
3
4
5
6
7
8
9
Highly energized
10
1 is Severely drained, 10 is Highly energized
Schedule flexibility
*
Very limited
1
2
3
4
5
6
7
8
9
Highly flexible
10
1 is Very limited, 10 is Highly flexible
Overall service capacity by service type or shift
*
Rows
Low capacity
Moderate capacity
High capacity
In-person patient care
1
2
3
Telehealth/remote support
4
5
6
Administrative tasks
7
8
9
Day shift
10
11
12
Evening shift
13
14
15
Night shift
16
17
18
Availability and Scheduling
Days Available
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Shift Types
Day Shift
Evening Shift
Night Shift
Weekend Shift
On-Call
Other
Hours per Week Available
*
Availability Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Constraints on Certain Days or Times
Preferred Service Mode
*
Onsite
Remote
Mixed
Workload and Assignment Limits
Maximum patients/clients per shift
*
Maximum patients/clients per day
*
Maximum consecutive shifts
Case types the worker can handle
*
Rows
Can handle
Can handle with support
Cannot handle
Routine follow-up
19
20
21
Acute/urgent care
22
23
24
High-acuity cases
25
26
27
Pediatric cases
28
29
30
Geriatric cases
31
32
33
Behavioral health cases
34
35
36
Infectious disease cases
37
38
39
Procedural/specialized care cases
40
41
42
Current caseload status
*
Please Select
Under capacity
At capacity
Near capacity
Over capacity
Not currently assigned
Support Needs and Resource Constraints
Support needs affecting your capacity
*
Supervision
Training
Equipment
Staffing support
Interpretation support
Scheduling accommodations
Other
Details or examples
Preferred support actions
One-on-one supervision
Group training
Equipment provision
Additional staffing
Language support
Adjusted scheduling
Workflow review
Other
Areas needing improvement
Additional Notes and Follow-up
Additional comments
Preferred follow-up contact method
Email
Phone
Text message
Any of the above
Would you like a capacity review follow-up?
*
Yes
No
Submit Assessment
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