Washington's attending providers use this two-page form to tell L&I, self-insured employers and vocational counselors what an injured worker can do at work and at home, whether time loss is certified, and what treatment is planned. It goes in with the report of accident when restrictions exist and again whenever work status, capacities or restrictions change, and claim managers use it to authorize time-loss benefits.
The attending provider (a doctor, including transfer, concurrent care and consulting doctors, an ARNP or a PA-C) completes the whole form and signs, checking the provider type. Occupational and physical therapists and office staff are not paid for working on it, and the worker completes nothing.
Enter the worker's name, patient ID (labels are allowed), visit date, claim number, your name, date of injury and diagnosis, using ICD codes or a written description of the primary diagnosis and reason for the visit. If the worker has more than one claim, list all claim numbers. The header shows where State Fund and self-insured APFs are sent.
Select at least one option: released to the job of injury without restrictions as of a date (then skip to Plans), modified duty from and to estimated dates, limited hours per day, already working modified duty or limited hours, not released to any work, or poor prognosis for return to the job of injury at any date. When selecting several, avoid gaps between the dates.
Required whenever the worker cannot return to full duty. List verifiable, documented findings from examination, lab tests or diagnostic procedures, such as a positive X-ray, swelling, muscle atrophy or decreased range of motion. Pain, tenderness and fatigue are subjective complaints and are not acceptable, and range-of-motion changes need measurements in the chart note.
Estimate how long current capacities apply, from 1-10 days to permanent, then rate each restricted activity from never to constant and leave the rest blank: sitting, standing, ladders, stairs, twisting, bending, squatting, crawling, reaching, overhead work, keyboarding, wrist motion, grasp, fine manipulation, foot controls and vibratory tasks by side, plus pounds for lifting, carrying and pushing. Capacities apply all day, every day.
Use Other Restrictions only when no listed capacity fits. Recording whether the employer was notified of capacities, whether modified duty is available, and the contact's name and date is optional but recommended. The Note to Claim Manager is optional and is the place to draw attention to specific issues on the claim.
Check all that apply: worker progress (slower than expected must be addressed in chart notes), current rehab, surgery status, new diagnosis, opioids for acute or chronic pain, next visit, treatment concluded at maximum medical improvement, permanent partial impairment and whether you will rate, refer or request an IME, care transfer, consultation or pending study. The next visit should fall no later than the estimated work status end date.
Check that a copy was given to the worker and that the three key messages on the back were discussed, then sign, date, add a phone number and mark doctor, ARNP or PA-C. The key messages cover the worker's role in recovery, how activity helps healing, and why early, safe return to work makes sense.
Download the current version from the source each time; forms change without notice.
Activity Prescription Form (APF)
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.
Sources for this guide
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Send it with the Report of Accident or Physician Initial Report when the worker has work-related restrictions, within 4 weeks of the claim established date for time-loss claims, and whenever work status, functional capacities or physical restrictions change, including when restrictions are removed. Claim managers, vocational counselors and self-insured employers can also request one.
Attending, transfer, concurrent care and consulting doctors, ARNPs and PA-Cs, who mark their provider type next to the signature. L&I will not pay occupational or physical therapists, office staff or others for working on the form. Impairment ratings mentioned on the back are for qualified doctors and department-approved chiropractic examiners.
Under code 1073M, a provider may submit up to 6 APFs per worker within the first 60 days of the initial visit and then up to 4 per 60 days. Each one is payable only when all required sections are complete and legible, and APFs and chart notes must be kept at least five years for audits.
Yes. Besides work status and restrictions, the APF certifies time-loss compensation when appropriate, and L&I claim managers use it to authorize time-loss benefits. The work status section, with dates for modified duty, limited hours or no work, documents the period, and objective findings are required whenever the worker is not released to full duty.