Report of Work Ability

The report of work ability form is used to assist the employee, employer and the workers’ compensation provider (MCIT) understand work restrictions related to the employee’s work-related injury covered under workers’ compensation.

Form Instructions

1. The employee takes the form to his or her medical provider for the provider to complete fully.
2. The employee returns the completed form to his or her supervisor after each medical appointment.
3. Employee should take a new form for each follow-up appointment.
4. Employees should contact their human resources department or supervisors with questions about the form.