Work Function Assessment - Welcome to My Practice

This self completed form is for patients who are applying for FMLA, short term disability or other functional accommodations in the workplace.

APA Foundation Work Function Assessment

(developed by the American Psychiatric Association Foundation for workplace mental health

Date
MM slash DD slash YYYY
Name
First Last
Can the Employee: 1) Comprehend and follow instructions?*
Can the Employee: 2) Maintain work focus/concentration despite usual disruptions?*
Can the Employee: 3) Organize complex information?*
Can the Employee: 4) Remember processes and details without repeated reminders?*
Can the Employee: 5) Remember and adhere to the usual workplace rules?*
Can the Employee: 6) Learn and retain new information timely?*
Can the Employee: 7) Maintain usual focus/concentration despite usual stresses?*
Can the Employee: 8) Take responsibility for completing usual work tasks?*
Please describe any other limitations or concerns you have about your abilities to comprehend, organize or complete work functions:*
Can the Employee: 9) Attend work regularly and timely?*
Can the Employee: 10) Sustain realistic energy through a regular work day?*
Can the Employee: 11) Appropriately follow through and complete tasks timely?*
Can the Employee: 12) Get along with peers and relate to others without undue irritability?*
Please describe any other limitations or concerns you have about your energy, abilities to get along with others, follow workplace rules and be timely:*
Can the Employee: 13) Capable of working on their own much of the time*
Can the Employee: 14) Maintain stable relationships in the face of usual stresses?*
Can the Employee: 15) Sustain thinking and focus in the face of usual stresses?*
Can the Employee: 16) Contain behavior despite frustration with negative persons or supervisors?*
Can the Employee: 17) Maintain appropriate work pace; remain on task until completion?*
Can the Employee: 18) Maintain organizational performance despite significant organizational stress/change?*
Can the Employee: 19) Engage and mortivate others effectively?*
Please describe any other limitations or concerns you have about your abilty to keep pace, take feedback from others or sustain work performance despite stress or change:*
Can the Employee: 20) Appearance, speech and actions are socially appropriate?*
Can the Employee: 21) Take responsibility for solving routine work problems?*
Can the Employee: 22) Understand their role in errors and omissions?*
Can the Employee: 23) Take responsibility for effect of behavior on productivity and on others?*
Can the Employee: 24) Deal realistically with others' errors and demands?*
Can the Employee: 25) Make realistic use of supervisory feedback?*
Please describe any other limitations or concerns you have about neurodiversity, personal style, accountability as it pertains to the workplace:*
Can the Employee: 26) Make effective independent decisions?*
Can the Employee: 27) Maintains appropriate boundaries with work authority and relationships?*
Can the Employee: 28) Effectively organize completion of multiple tasks at the same time?*
Can the Employee: 29) Anticipate barriers to task completion?*
Can the Employee: 30) Delay responses when appropriate?*
Can the Employee: 31) Organize and manage projects and/or processes independenty?*