Functional Abilities Form (WORKPLACE INJURY)

Question 1

Functional Abilities Form (workplace injury)

VERY IMPORTANT

A FAFF is required when ?

1. When coming back to FULL time duties AFTER ?
2. For EVERY workplace injury resulting in ?
3. IF returning or not returning to what? After a workplace injury
4. How often? AFTER 1ST Dr’s visit ?

Answer 1

1. AFTER a workplace injury
2. LOST TIME and/or MEDICAL CARE
3. If returning or not returning TO MODIFIED after workplace injury
4. Once a Month AFTER 1ST Dr’s visit

Question 2

Functional Abilities Form (workplace injury)

How often

is a FAF required?

Answer 2

Every Month after the 1st DR visit

Question 3

Functional Abilities Form (workplace injury)

number one is good question

FAFF

1. Who fills out section A
2. Who fills out section B
3. Who fills out section C
4. Who fills out section D,E,F

Answer 3

SECTION A

*Employee OR Employer*

SECTION B

Employee signature

SECTION C

Physician Billing Info

SECTION D,E,F

Physician

Question 4

Functional Abilities Form (workplace injury)

FAFF

What section does a DR fill out ? (A,B,C,D,E,F)

Answer 4

DR’s fill out section C, D, E, F

Question 5

Functional Abilities Form (workplace injury)

What section is filled out

1. By DR and includes all functions ?

Answer 5

SECTION D

SAME FOR MAFF