Cognitive and Behavioral Capacities Evaluation Form

Jenny HaykinCompliance, Resources, Sample Forms, Policies and Documents


King County Government developed two forms to facilitate accommodations for workers with diagnosed mental, behavioral or learning impairments. Jenny Haykin, who was the Disability Services Team Lead for King County, worked with the county’s team of vocational rehabilitation counselors and area psychiatrists to develop the following forms for health care providers to assess the worker’s capacities and limitations when evaluating or treating employees with cognitive and psychiatric conditions. Haykin has continued to use these forms in her present role at the Leaves & Accommodations Program Manager at Puget Sound Energy:

Both forms use the same cognitive and behavioral capacities so they may be used separately or in conjunction with one another.

The Cognitive and Behavioral Capacities Evaluation Form and the Cognitive and Behavioral Job Analysis seek the provider’s opinion on the employee’s capacity in comprehension, memory, learning, processing information, task completion and work behaviors. For example, is the employee able to remember written instructions, maintain emotional control under stress, direct others in complex tasks or respond effectively to emergencies? This information is then used to help the representative (typically a vocational counselor) work with the employee and their supervisor to make specific adjustments in their work tasks to accommodate the employee’s disability.

The procedure for using the forms begins when it becomes known there is a cognitive or behavioral medical issue or learning disability impacting job performance. The employee or a vocational rehabilitation counselor, case manager or human resources representative (all with permission from the employee) then provides information to the health care provider or learning disability specialist on the nature of the job.

At the same time, information about work performance concerns and specific questions are provided. This educates the health care provider or learning disability specialist so that as they make their assessments, they will better understand what is expected of the employee at work, and what information the employer will need to be able to facilitate potential accommodations with the employee.

Haykin has found that employees are quite willing to allow this exchange of information with their care provider with the understanding that the performance or behavioral issues will need to be addressed. It is preferable for this to occur through accommodation rather than through a disciplinary process.

This article was excerpted from an Employer Case Example about Puget Sound Energy from the Partnership for Workplace Mental Health.


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