Every Minnesota provider directing an injured worker's treatment must report work ability on this form or an equivalent report. The provider marks one of three options, able to work without restrictions, able with restrictions, or unable to work, with start and end or review dates, describes restrictions in functional terms, and sets the next visit. The employee receives it and passes copies on to the employer, insurer and rehabilitation consultant.
The health care provider directing the course of treatment completes and signs the whole form, with degree and license or registration number.
Download the current version from the source each time; forms change without notice.
Report of Work Ability
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.
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Under Minnesota Rules 5221.0410, subp. 6: at every visit if visits are less frequent than once every two weeks, every two weeks if visits are more frequent unless restrictions change sooner, when previous restrictions reach their ending or review date, and within 10 days of an insurer's request.
Yes, if it contains the same information: employee name, WID or Social Security number, date of injury, employer, insurer and claim number if known, date of the most recent exam, the work ability option with dates, the next visit, and the provider's identification and signature.