Pre-Employment Functional Capacity Evaluation Form
Please complete this assessment to evaluate the candidate’s functional abilities relevant to the job requirements.
Candidate Full Name
*
First Name
Last Name
Position Applied For
*
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
Mobility Assessment
*
Rows
Unable
With Assistance
Independent
Walking
1
2
3
Standing
4
5
6
Climbing Stairs
7
8
9
Lifting Capacity (in kilograms)
*
Less than 5 kg
5-10 kg
11-20 kg
More than 20 kg
Endurance Rating
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Upper Limb Coordination
*
1
2
3
4
5
Any pain or discomfort reported during assessment?
*
No
Yes - Mild
Yes - Moderate
Yes - Severe
Evaluator Comments
Submit Evaluation
Should be Empty: