Work Hardening Evaluation Form
Evaluate work tolerance, restrictions, progress, and next steps for a work hardening participant.
Participant & Evaluation Details
Participant Name
*
First Name
Last Name
Evaluator Name
*
First Name
Last Name
Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Department or Employer/Worksite
*
Evaluation Type or Phase
*
Initial Evaluation
Progress Review
Discharge Evaluation
Other
Work Tolerance Assessment
Current work status
*
Not yet ready
Modified duty
Transitional duty
Full duty
Other
Tolerance for lifting, carrying, pushing, and pulling
*
Very limited
1
2
3
4
5
6
7
8
9
Full tolerance
10
1 is Very limited, 10 is Full tolerance
Standing/walking tolerance (minutes)
*
Sitting tolerance (minutes)
*
Overhead/repetitive task tolerance
*
Unable
Limited
Moderate
Full tolerance
Other
Restrictions, Goals, and Next Steps
Current Restrictions or Limitations
Functional Goals for the Next Phase
Recommended Work Modifications or Accommodations
Evaluator Summary and Readiness Recommendation
*
Please Select
Continue Work Hardening
Advance to Next Level
Transition to Work
Discharge
Other
Follow-up Review Date or Next Appointment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: