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Workers' compensation -- Forms



Report of Work Ability

Who is responsible for completing the form?

  • It is the primary health care provider's responsibility to complete the form. The primary health care provider is the individual health care provider directing and coordinating medical care to the employee.

  • In lieu of completing the Report of Work Ability form, the primary health care provider may respond in a narrative report that contains the same information requested on the form.

Why is this form needed?

  • The purpose of this form is to provide the employee, employer, insurer, qualified rehabilitation consultant or commissioner with information about the employee's work restrictions.

What, specifically, is this form used for?

  • To advise the employee of functional restrictions that may affect daily activities

  • To assist the employer in bringing the employee back to a job at work that is within the employee's physical restrictions.

  • To comply with statutes and rules:

    • Minnesota Statutes 176.231, subd. 3, 5 and 6, 7

    • Minnesota Statutes 176.251

    • Minnesota Rules 5221.0410, subp. 6

When is this form completed?

  • The health care provider must complete this form:

    • within 10 days of a request by an insurer, or

    • every visit, if visits are less frequent than once every two weeks;

    • every two weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner;

    • upon expiration of the ending or review date of the restriction specified in previous reports of work ability

Where is this form sent?

  • The health care provider can give the form to the employee at the office visit.

  • The employee sends the form to the employer or insurer and the qualified rehabilitation consultant, if one has been assigned to the case.

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