Incapacity For Work Questionnaire

Incapacity for work questionnaire is a set of questions which are designed to assess incapability of employees to work at their work places during periods of illness, physical injury or depression.

Incapacity For Work Questionnaire Sample

Name :              _________________________________________________________________

Employee Code:  ___________________________________________________________

Name of the person fulfilling this form stating reason and relationship:

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Your telephone no:              ________________   _________________        __________________

Daytime         Office                   Mobile

1. Kindly tell us about disability or illness

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1. Are you being treated by a doctor? Are you receiving any care or help from others? Any treatment from hospitals? If yes please furnish contact and details.

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1. Do you think that your present condition is attributed to drug, alcohol misuse or misuse of other substance?

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1. Are you able to walk:-
   1. Ground level without difficulty?
   2. Ground level up to 200 yards, and then need to stop
   3. Two or three staircases up or down

1. Are you able to sit and stand? If not please brief us about your difficulties.

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1. Are you able to bend and kneel without difficulty? If not please brief us about your difficulties.

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1. Are you able to use your arms to pick up objects at same level? Are you able to reach top or bottom shelves? If not please brief us about your difficulties.

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1. Any problems in speech, sight or hearing? Describe briefly.

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1. Any problems in keeping awake and conscious?

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1. Any problem in focusing or concentrating?

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1. Any problem in socializing, group activity?

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1. Any other problems?

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