Music Teachers: Work Capabilities Form
Patient name:
Patient injury:
Patient will be able to participate in light duties as below from:
Full time
Part time
hours per day
School/location duties are performed at:
Teaching Activities
/
/
to / /
days/week
Limitations/Comments
Projecting voice (e.g. across classroom/playground)
Playing musical instrument
Wood wind
Percussion
Brass
Moving equipment – instruments and music stands
Conducting ensembles before school and during breaks
Managing a small group of students for
half day
full day
Supporting another teacher
Planning lessons
Assessing students’ work
Non Teaching Activities
Standing for longer than two hours
Walking up stairs
Bending
Repetitive bending
Turning/twisting or extending
Lifting hand or hands above head
Sitting position only
Siting on low level chairs
Lifting weights more than
kg
Keyboarding/computer work
Concentration on tasks for longer than
min/hrs
Interacting with other staff
Extracurricular activities
Itinerant teaching including travel between schools
Comments:
SIGNATURES
Treating Medical Practitioner:
__________________________________________
____ / _____ / _____
Employee:
__________________________________________
____ / _____ / _____
Rehabilitation & Return to Work Coordinator:
__________________________________________
____ / _____ / _____