Vermont's Department of Labor publishes this form so a treating clinician can document the work ability of a patient whose injury or illness affects cognitive function. Abilities in three categories, cognition, self-regulation and resilience, are rated, and job modifications are chosen for each. The result can release a patient to work, guide accommodations or vocational placement, and support workers' compensation, disability or SSDI claims.
The treating medical or psychiatric provider completes and signs it. Occupational therapists, speech-language pathologists, neuropsychologists, clinical psychologists and counselors may complete sections within their professional scope as a communication tool with the primary treating provider.
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Cognitive Work Capabilities Form
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The treating medical or psychiatric provider signs it. The quick guide also lets occupational therapists, speech-language pathologists, neuropsychologists, clinical psychologists and counselors complete sections within their professional ability, as a way to communicate with the primary treating provider, whose name and signature close the form.
Yes. Vermont's quick guide lists uses beyond workers' compensation: releasing a patient to work, helping an employer put accommodations in place, helping a vocational rehabilitation counselor with placement, and documenting work disability for short or long term disability or Social Security Disability Insurance.
The guide suggests a functional interview using concrete examples from self-care, home management and job performance, such as asking whether the patient can cook several foods at the same time to gauge multitasking. It also asks raters to stay aware of unconscious biases related to age, race, education or socioeconomic status.