FORM TWCC-74a
FUNCTIONAL RESTORATION REPORT INSTRUCTIONS
PART I:
GENERAL INFORMATION - Contains space to record general information about the employee and the
doctor/clinic. This section includes space to record the date employee was first seen for injury, date of this office visit and if
initial or follow-up visit. Also contains space to record the name and facsimile number or email address of the insurance
carrier (carrier) and the employer, as well as the date of transmission. This space is intended to eliminate the need for a
separate facsimile cover page. Because this information is intended primarily for transmission purposes, the report
may be provided to the injured employee (employee) at the time of the examination, even if the information required
in this section is not yet available.
PART II: ACTIVITY CAPABILITIES - The doctor is to indicate the activity capabilities that apply in this section or a notation
that no restrictions are recommended. The doctor is only supposed to indicate what capabilities are in place because
of the workers= compensation injury. Any restrictions that may have existed due to other conditions are assumed to
remain and should not be duplicated here. The doctor should go over the activity capabilities with the employee at the time
the report is provided.
The section was designed to include check boxes for capabilities that may apply to the employee. At least one box must be
checked in sections 13, 15, 16, either check the no restrictions box or check one of the boxes for each individual activity in
the section. If the No Restrictions box is checked, it is understood that the employee is capable of performing that activity. In
box 14, if whole body restricted box is checked, then it should be understood that the restrictions are to the whole body.
Provide any other activities and/or information that have not been addressed or need further clarification in box 19.
PART III: GENERAL TREATMENT/FOLLOW-UP INFORMATION - Provides upcoming appointment information (if known
at time of filing report) so that the carrier can better manage the claim and the employer can be aware of time when the
employee might not be available for work due to scheduled follow up services. In addition, providing this information may
reduce calls from carriers and employers seeking the information.
The Functional Restoration Report is designed to be filed by the treating doctor. Other doctors may be required to use this
form by commission rules.
Basic Instructions
Treating Doctor: The FR Report shall be provided to injured employee at time of examination and at the time of any
subsequent office visit or examination whenever any of the factors identified in Part II, Activity Capabilities section have been
modified and shall be provided to the employer and the carrier, by facsimile, electronically, personal delivery, or mail, not later
than the end of the second working day following the date of the examination.
The treating doctor shall prepare a subsequent FR report if any information provided to the treating doctor results in a
modification to factors identified in Part II, Activity Capabilities section. The subsequent report shall be provided to the
employee by facsimile or electronic transmission, if the doctor has that contact information; otherwise, the report shall be
provided by mail, and sent to the employer and the carrier by facsimile, electronically, personal delivery, or mail, not later
than the end of the second working day following the date of the report.
Rule 130.1104 provides the complete requirements for filing this report. The complete text of the Disability Management
rules are available on the Commission=s web site at www.twcc.state.tx.us.
Instructions for Functional Restoration Report
Rule 134.1104
TEXAS WORKERS' COMPENSATION COMMISSION
Employee - You are required to report your injury to
your employer within 30 days if your employer has
workers= compensation insurance. You have the right
to free assistance from the Texas Workers=
Compensation Commission and may be entitled to
certain medical and income benefits. For further
information call your local Commission field office or
1(800)-252-7031.
Trabajador - Es necesario que usted reporte su lesión a su
empleador dentro de 30 días a partir del día en que se lesionó,
si su empleador tiene seguro de compensación para
trabajadores. la Comisión Tejana de Compensación para
Trabajadores le ofrece asistencia gratuita, también puede que
usted tenga derecho a ciertos beneficios médicos y monetarios.
Para mayor información llame a la oficina local de la Comisión
1-800-252-7031
TEXAS WORKERS= COMPENSATION FUNCTIONAL RESTORATION REPORT
PART I: GENERAL INFORMATION
5. Doctor's Name and Licensure
(for transmission purposes Date Being Sent
only)
1. Injured Employee's Name
6. Clinic/Facility Name
2. Date of Injury 3. Social Security Number
7. Clinic/Facility/Doctor Phone & Fax
10. Employer=s Fax # or Email Address (if
known)
4. Date first seen for injury
8. Clinic/Facility/Doctor Address (street address)
11. Insurance Carrier
City
12. Carrier=s Fax # or Email Address (if known)
9. Employer's Name
Date of this office visit
G
G
Initial
Follow-up
State
Zip
PART
II: ACTIVITY CAPABILITIES - APPLICABLE BOTH AT WORK AND OUTSIDE OF WORK.
tttt
(At least one box must be checked in each of sections 13 - 18)
15. MOTION CAPABILITIES:
13. POSTURE CAPABILITIES:
G
No restrictions
Max Hours per day:
0
2
4
6
G
No restrictions
8
Other
Max Hours per day:
0
Standing
G
G G G G ___
Walking
Sitting
G
G G G G ___
Climbing stairs/ladders G
Kneeling/Squatting
G G G G G ___
Grasping/Squeezing
Bending/Stooping
G G G G G ___
Wrist flexion/extension G
Pushing/Pulling
G G G G G ___
Reaching
G G G G G ___
Other: _____________
G G G G G
___
Twisting
14. CAPABILITES SPECIFIC TO (if applicable):
No restrictions
G
G
G
G
G
Whole Body Restricted
L Hand/Wrist
L Arm
L Leg
G
G
L Foot/Ankle
G
R Leg
G
G
G Other: ________
R Hand/Wrist
R Arm
G
G
17. MISC. CAPABILITIES:
Neck
Back
R Foot/Ankle
G
2
4
6
G
No restrictions
8
Other
G G G G ___
G
G
Max hours per day of work: _______
Sit/Stretch breaks of ______ per ______
G G G G ___
G
Must wear splint/cast at work
G G G G G ___
G
Must use crutches at all times
G G G G ___
G
G
G
G G G G G ___
G G G G G ___
Keyboarding
G G G G G ___
Other: _____________
G G G G G
16. ___
LIFT/CARRY CAPABILITES:
No restrictions
G
G May not lift/carry objects more than ___lbs.
Overhead Reaching
No driving/operating heavy equipment
Can only drive automatic transmission
Duties may not include __ hours/day:
G
G
G
G
G
in extreme hot/cold environments
at heights or on scaffolding
Must keep __________________
Elevated
G
Clean & Dry
No skin contact with: ________________
(approximate)
for more than ____ hours per day (approximate)
G
G
May not perform any lifting/carrying
Other: ________________________________
G
G
G
G
Dressing changes necessary at work
No Running
No Walking on uneven surfaces
No Activities requiring depth perception
19. OTHER:
18. MEDICATIONS WHICH MAY IMPACT WORK CAPABILITIES:
G NONE
G Prescription medication(s)
G Advised to take over-the-counter medication(s)
G
to take
meds safety/driving issues)
G Advised
Medication
may over-the-counter
make drowsy (possible
PART III: REFERRAL / CONSULTING DOCTOR OR NEXT APPOINTMENT INFORMATION
20.
G Next evaluation by the treating doctor on _________ at_ __am/pm.
G
21.
G Referral to/Consult with
for
for
None. This is the last scheduled visit.
EMPLOYEE=S SIGNATURE
Instructions for Functional Restoration Report
for
DOCTOR=S SIGNATURE
Rule 134.1104
TEXAS WORKERS' COMPENSATION COMMISSION