Vermont's Workers' Compensation Division recommends this one-page form for medical providers assessing the work capabilities of patients with work injuries. After an exam, the provider either releases the worker without restrictions, lists capacities for standing, sitting, driving, lifting, bending, reaching and other activities, or states the worker may not return and estimates how long total disability will last.
The treating medical provider completes and signs the capabilities section. The patient signs the authorization at the bottom, allowing the provider to release information about the injury to the employer or its representative.
Download the current version from the source each time; forms change without notice.
Work Capabilities Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The form describes itself as recommended for medical providers assessing the work capabilities of patients with work injuries. Using it gives the employer and insurer restrictions in a consistent format, with the patient's release to the employer already on the same page.
Yes, at the bottom. The patient's signature authorizes the medical provider to release information acquired during examination or treatment for the injury to the employer or its representative, which allows the completed form to be shared with the employer and its insurer.