Work Function Assessment Form Survey Work Function Assessment Form Survey The Work Function Assessment Form is provided to help you determine a patient’s capacity to function effectively at his or her job. Please evaluate the usefulness of the form by filling out this survey. OK Question Title * 1. This form contains the right questions to help determine an individual's work function capacity. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other (please specify) OK Question Title * 2. I will use this form as a regular practice in my professional setting. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other (please specify) OK Question Title * 3. The impairment scale contains all the components needed to move beyond a person's diagnostic condition to work functionality. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other (please specify) OK Question Title * 4. My overall experience using the Work Function Assessment Form was positive. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other (please specify) OK Question Title * 5. This form helped me more accurately determine Activities of Daily Living. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other (please specify) OK Question Title * 6. This form helped me more accurately determine Social Functioning. Strongly Disagree Disagree Agree Strongly Agree Strongly Disagree Disagree Agree Strongly Agree Other (please specify) OK Question Title * 7. This form helped me more accurately determine Concentration, Persistence and Pace. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other (please specify) OK Question Title * 8. This form helped me more accurately determine Performance of Mental-Interpersonal, Time-Management and Physical Tasks. Disagree Strongly Disagree Agree Strongly Agree N/A Disagree Strongly Disagree Agree Strongly Agree N/A OK Question Title * 9. In the last three months, how often have you used this form? 5 times per month or more 2-4 times Only once I haven't used this form Other (please specify) OK Question Title * 10. I prefer this form over any other disability form. Strongly Disagree Disagree Agree Strongly Agree N/A Strongly Disagree Disagree Agree Strongly Agree N/A Other comments (please specify) OK DONE