Client number: ____ Date: ________

1. Have you worked since your functional capacity evaluation (FCE)? ____Yes ____No (If the answer to question 1 was "no" please indicate the reason or reasons):

____ unemployed
____ no modified duty job available
____ job searching
____ not medically released
____ other (please describe)
__________________________________________________
__________________________________________________
__________________________________________________

2. Are you currently working? ____Yes ____No (If the answer to question 2 was "no" please indicate the reason(s):

____ unemployed
____ no modified duty job available
____ job searching
____ not medically released
____ other (please describe)
__________________________________________________
__________________________________________________
_________________________________________________

(If you answered "no" to question 2, please go question 9.)

3. How many hours per week do you work? ____ Hours

4. Please list the recommendations you recall regarding work and/or exercise that were made of your FCE report: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

5. Which best describes you current job?

____ same employer, same job
____ same employer, same job modified
____ same employer, different job
____ different employer, similar job
____ different employer, different job
____ other (Please describe)_______________________________
______________________________________________________
______________________________________________________

6. If your current job is not the same as the first one you had after your FCE, which best describes your first job after you completed the FCE?

____ I have not changed jobs since the first one I had after my FCE.
____ same employer, same job
____ same employer, same job modified
____ same employer, different job
____ different employer, similar job
____ different employer, different job

7. If your current work is the same or similar to the work you did before your injury, what type of modifications have been necessary?

____ none
____ less lifting
____ fewer hours
____ other (Please explain:)________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

8. What are your current work demands?

____ sedentary (Lift 10 lbs. maximum)
____ light (Lift 20 lbs. maximum)
____ medium(Lift 50 lbs. maximum, frequent lift up to 25 lbs.)
____ heavy(Lift 100 lbs. maximum, frequent lift up to 50 lbs.)
____ very heavy(Lift over 100 lbs. occasionally)

9. If you returned to work, did you return to work within the recommendations of your FCE report? ____Yes ____No (If "no" please explain how your work situation differs/differed from the recommendations:

____________________________________________________________
____________________________________________________________
____________________________________________________________

10. Have you been reinjured since your FCE? ____ Yes ____ No (If "yes" please describe the injury and its circumstances:)

____________________________________________________________
____________________________________________________________
____________________________________________________________

11. Do you believe your physical capabilities have changed since your FCE? ____ Yes ____ No (If "yes" please check one:)

____ my physical capabilities have improved (Please explain)
____ my physical capabilities have declined (Please explain)
_______________________________________________________
_______________________________________________________
_______________________________________________________

12. What were your work demands at the time of your injury?

____ sedentary (Lift 10 lbs. maximum)
____ light (Lift 20 lbs. maximum)
____ medium(Lift 50 lbs. maximum, frequent lift up to 25 lbs.)
____ heavy(Lift 100 lbs. maximum, frequent lift up to 50 lbs.)
____ very heavy(Lift over 100 lbs. occasionally)

13. Do you (or did you) have an attorney working with you regarding your injury? ____ Yes ____ No

14. Has your case been closed? ____ Yes ____ No (If not, please check all that apply:)

____ legal issues not resolved
____ continued medical treatment
____ job search
____ retraining
____ not working at full duty
____ other (Please explain)
_______________________________________________________
_______________________________________________________
_______________________________________________________

15. Please rate your satisfaction level with each of the following, using the scale below.

1 — 5, where 1 is very satisfied, 3 is average, and 5 is very dissatisfied.

A ____ explanation of the purpose of the FCE
B ____ explanation of the results of the FCE
C ____ accuracy of the FCE results compared to your physical abilities
D ____ respect you were shown by the therapist during the FCE
E ____ overall satisfaction with the FCE
F ____ your dealings with your physician(s)
G ____ your dealings with your therapist(s)
H ____ your dealings with your insurance representative(s)
I ____ your dealings with your employer at the time of your injury or medical difficulties
J ____ assistance provided to you by your case manager or rehabilitation counselor
K ____ your current work status
L ____ your job before your injury

16. What was the most positive aspect of the FCE?

____________________________________________________________
____________________________________________________________
____________________________________________________________

17. What suggestions can you make for improving the FCE?

____________________________________________________________
____________________________________________________________
____________________________________________________________

18. Would you like to receive information about the results of this study? ____ Yes ____ No

Thank you very much for helping us!

*Slight modifications have been made to this survey since it was used in the follow-up study.

• Core Lifts
• Unilateral Carry
• Bilateral Carry
• Push/Pull
• Grip
• Squatting
• Balance
• Stair Climbing
• Sustained Mid-Level Reach
• Sustained Elevated Reach

• Custom Lifts
• Ladder Climb
• Sit
• Stand
• Walk
• Kneel
• Crawl
• Crouch
• Pinch
• Repetitive Foot Motion
• Hand Coordination

Astrand, P., & Rodahl, K. (1986). Textbook of work physiology. New York: McGraw-Hill.

King, P.M., Tuckwell, N., & Barrett, T.E. (1998). A critical review of functional capacity evaluations. Physical Therapy, 78, 852-866.

Mital, A., Nicholson, A.S., & Ayoub, M.M. (1993). A guide to manual materials handling. Washington, D.C.: Taylor & Francis.

Selan, J.L. (Ed.). (1994). The advanced ergonomics manual. Dallas: Advanced Ergonomics, Inc.

United States Department of Labor, Employment and Training Administration. (1991). Dictionary of occupational titles, (4th ed.) (rev.). Washington, D.C.: U.S. Government Printing Office.

United States Department of Labor, Employment and Training Administration. (1991). The revised handbook for analyzing jobs. Washington, D.C.: U.S. Government Printing Office.