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Functional Testing Informed Consent
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During this evaluation you will be asked to perform a variety of tasks. It is very important that you perform the tasks that I ask you to perform but it is equally important that you perform the tasks without hurting yourself.
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You are in control of this evaluation. You may choose to stop any test at any point for any reason. If you terminate a test, you will be asked why you feel stopping is necessary.
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As with any activity, there is a risk that you may injure or re-injure yourself during this evaluation. Every attempt will be made to avoid this. By initialing this paragraph, you are indicating that you understand this.
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You will benefit from this evaluation as it will help you to identify your ability to perform work-related tasks. By initialing this paragraph, you are indicating that you understand this.
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You may be asked to stop testing if necessary and you will be informed of the reason(s) in such cases. One of these may be because the evaluation feels you may be injured if allowed to continue.
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It is very important that you try your best during every test in this evaluation. By initialing this paragraph, you are indicating that you understand this.
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It is very important that you report your abilities and symptoms as accurately as possible before and during the evaluation. By initialing this paragraph, you are indicating that you understand this.
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I, ___________________________ understand and agree to comply with these instruction. (Name)
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Patient's Signature
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Date
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Evaluator Signature
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Date
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Functional Capacity Exam: Tier 3
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Step Test Criteria(Passed/Failed)
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As a part of this functional capacity exam, applicants will be required to complete a three-minute aerobic step test before completing any of the essential testing criteria for their specific position in which they are applying.
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This test is not job specific but used as an assessment tool. During this step test, the heart rate is monitored to determine an applicant's aerobic fitness level.
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An applicant will be required to get a medical release from their private physician if any of the following situations occur:
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a) Blood pressure exceeds 200 mmHg at any time during the step test
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b) Heart rate does not fall under 100 beats/minute following completion of the step test in a reasonable amount of time (less than 10 minutes)
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c) An abnormal heart rhythm is detected before, during or after test
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Blood Pressure (--/--) :
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Pulse:
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Height:
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Weight:
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Essential Testing Criteria(Passed/Failed)
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Able to stand throughout evaluation
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Comments (if failed)
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Sit and Reach
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Comments (if failed)
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Range of motion
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Comments (if failed)
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Lift 80 lbs from floor to knuckle x2
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Comments (if failed)
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Lift 50 lbs from floor to waist x2
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Comments (if failed)
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Lift 50 lbs from floor to shoulder x2
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Comments (if failed)
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Lift 40 lbs from floor to head x2
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Comments (if failed)
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Carry 75 lbs for 10 feet
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Comments (if failed)
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Pull horizontally with peak force of 75 lbs with 2 hands
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Comments (if failed)
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Push horizontally with peak force of 75 lbs with 2 hands
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Comments (if failed)
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Climb up and down 24 steps carrying 45 lbs
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Comments (if failed)
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Climb slanted ladder 10 rungs 2 reps (self-paced but continuous)
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Comments (if failed)
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Kneel to stand: kneel 30 seconds, stand, kneel 30 seconds, 5 reps
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Comments (if failed)
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Squat 60 seconds
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Comments (if failed)
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Crawl for a distance of 20 ft
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Comments (if failed)
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Maneuver through hatch without difficulty
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Comments (if failed)
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Client Signature
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Date
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Evaluator Signature
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Date
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