Tip for Evaluator-specific

Give maximum honest effort during the FCE — evaluators use validity testing to detect sub-maximal effort

Tip for Evaluator-specific

Report ALL pain and limitations during the evaluation — do not push through pain silently

Tip for Evaluator-specific

Request a copy of the final FCE report for your records

Social Security DisabilityhardDoctor signature required

Functional Capacity Evaluation (FCE) Report

Evaluator-specific · Disability Insurance Carriers / Independent Evaluators

Comprehensive physical assessment of the claimant's ability to perform work-related tasks including lifting, sitting, standing, and walking. Typically 4-6 hours of testing.

Form Details

Total fields: 80
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Filled by: doctor
Frequency: per incident

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Where to Submit This Form

📬

Submit to the requesting party (insurer, employer, or attorney)

FCE is conducted by a licensed physical or occupational therapist.

Required Attachments

📎 FCE must be performed by a certified evaluator (PT or OT)
📎 Full evaluation report documenting objective functional limitations
📎 Comparison of functional abilities to job demands (if applicable)

Processing Time

FCE evaluation takes 4-8 hours. Report is typically completed within 1-2 weeks of the evaluation.

What Happens Next

The FCE report provides objective evidence of your physical functional capabilities and limitations. It is used by insurers, SSA, or employers to determine disability status or return-to-work readiness.

Tips for This Form

✓ Give maximum honest effort during the FCE — evaluators use validity testing to detect sub-maximal effort
✓ Report ALL pain and limitations during the evaluation — do not push through pain silently
✓ Request a copy of the final FCE report for your records

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Work History Report

SSA-3369-BK · SSA

10-page report requiring detailed descriptions of all jobs held in the past 15 years including physical demands, tools used, supervision, and lifting requirements.

Function Report

SSA-3373-BK · SSA

10-page functional assessment covering ADL capacity, daily routines, social functioning, cognitive abilities, and physical limitations.

Authorization to Disclose Information

SSA-827 · SSA

Authorization allowing SSA to collect medical and other information from providers, hospitals, and other sources for disability determination.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Disability Insurance Carriers / Independent Evaluators or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.