Functional Capacities #2
The following assessment is converted from an assessment used by Iowa Vocational Rehabilitation Services. All responses should be based on the individuals disability.
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Name of Individual being evaluated: *
Person Completing Form: *
1. MOBILITY
Unable to move safely, including changing body position, without help or advice. *
If yes, please explain:
Takes significantly longer to move about. *
If yes, please explain:
Cannot drive due to physical or mental problems *
If yes, please explain:
Other limitations *
If yes, please explain:
2. SELF CARE
Requires home modifications to perform self-care tasks in order to get to work. *
If yes, please explain:
Is restricted/limited in the ability to perform average daily living activities to get ready for work *
If yes, please explain:
Requires a personal assistant, guardian, public administrator, payee or community support worker for self care skill deficits in order to work. *
If yes, please explain:
Has episodes of repeated hospitalizations and problems with stability. *
Other limitations *
If yes, please explain:
3. SELF DIRECTION
Needs adaptive equipment to do tasks. *
Has a case manager/social worker due to the disability *
Has difficulty performing tasks without modifications *
Has serious difficulty concentrating on tasks, organizing and following through on expectations. *
Requires detailed directions to adequately plan activities *
Demonstrates impulsivity and poor judge not typically seen in individuals of comparable age, education and experience which results in legal problems or equally negative consequences that impact employment. *
Has episodes when assistance/monitoring or personal assistance is needed to do tasks. *
Other limitations *
If yes, please explain:
4. WORK SKILLS
Does not have work skills usually possessed by individuals of comparable age, education, and experience. *
Requires instructions to be paired with multiple strategies, as compared to peers, to learn work skills. *
Requires assistive technology, adaptive equipment, or prosthetic to perform work skills. *
Requires a personal assistant or a job coach to learn and/or perform work skills *
Has difficulty performing fine and gross motor skills required by work tasks. *
Requires extra time to adequately perform tasks. *
If yes, please explain:
Other limitations *
If yes, please explain:
5. WORK TOLERANCE:
Has difficulty tolerating common work environmental factors. *
If yes, please explain:
Has difficulty tolerating common work psychological stresses. *
If yes, please explain:
Has difficulty tolerating common physical demands of the job. *
If yes, please explain:
Requires adaptive equipment and/or work schedule to meet job training demands *
If yes, please explain:
Other limitations *
If yes, please explain:
6. INTERPERSONAL SKILLS:
Exhibits emotional behaviors which interfere with work/training with coworkers and managers. *
Requires monitoring, behavior management, accommodations or adaptations, not typically made for other employees to develop or maintain working relationships. *
Lacks insight into self that results in a lack of tact/diplomacy which creates difficulties in maintaining work relationships. *
Other limitations *
If yes, please explain:
7. COMMUNICATION
Cannot hear/understand ordinary speech *
Has difficulty reading or writing beyond simple sentences typically found in middle school level and in comparison to peers of equivalent age. *
Requires an interpreter or other hearing accommodation to obtain employment. *
Requires a reader or other accommodation to read in order to obtain employment. *
Cannot readily be understood on first contact. *
Other limitations. *
If yes, please explain:
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