Name: Mr.

XXX XXX
Date of Report: XXX XXX
Page 9 of 23

SECTION 1: SYMPTOM AND ACTIVITY BEHAVIOUR CHART

Date: June 23, 2011

Day: 1 of 2

(eg. verbal,
grimace)

(e.g. head)

9:40
arrived

OBSERVATIONS AND COMMENTS

Other:

participation of
task

Fatigue

completed

Dizzines

Duration of
Task (Mins)

Table 1: The following is a summary of the claimants completed tasks and reported symptoms for the first day
ACTIVITY
CLAIMANT REPORTED
SYMPTOMS
TIME
TASK
Performance
Engagement Expressio Location
Persistence in
Quality
% of task
DESCRIPTION
n of Pain
of Pain

Ingested oxycontin @ 6:30

9:43
9:57

Mail Sort

14

100%

10:00
10:05

Alphabetizing

100%

10:06
10:12

Visual Maze

100%

Moaning

back

Back

Requires break every 10-15 minutes

10:13
10:16

Payroll
Computation

10:17
10:26

Patient
Information
Memo

100%

100%

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 10 of 23

10:26
10:34

Small Parts

10:39
11:51

Small Parts
B 1 & B2

75%

11

50%

% of task
completed

Persistence in
participation of
task

(eg. verbal,
grimace)

(e.g. head)

OBSERVATIONS AND COMMENTS

Other:

Engagement

Fatigue

Quality

Performance

CLAIMANT REPORTED
SYMPTOMS
Expressio Location
n of Pain
of Pain
Dizzines

TASK
DESCRIPTION

Duration of
Task (Mins)

TIME

ACTIVITY

This is stupid

Mini break: 5 minutes

10:54
10:58

Ruler
Reading

100%

10:59
11:02

Pipe Assembly

100%

11:04
11:06

O-Rings

100%

11:07
11:11

Block design

100%

Color Sort

100%

11:12
11:14

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 11 of 23

11:16
11:20
11:45
12:40
12:40
1:00

% of task
completed

Persistence in
participation of
task

100%

(eg. verbal,
grimace)

(e.g. head)

OBSERVATIONS AND COMMENTS

Other:

Engagement

Fatigue

Quality

Performance

CLAIMANT REPORTED
SYMPTOMS
Expressio Location
n of Pain
of Pain
Dizzines

TASK
DESCRIPTION

Duration of
Task (Mins)

TIME

ACTIVITY

Circuit Board
Client extended lunch 10 minutes
Lunch

55

Interview
R of M
Grip Strengths

20

1:01
1:26

Data Entry
(computer
station)

25

100%

1:28
2:05

Collating
( paper work )

39

100%

2:09
2:25
2:25

Selecting and
sorting

16

30%

Back

Sighing

Back

Required detailed directions

client reported increased back pain

Independent; able to move around twisting and

bending
Break:10 minutes
Unable to continue due to pain.

Day one
finished

Rating of Activity Performance/Engagement:

1 Performance of task was completely unacceptable for employment (1-39%)
2 Performance of task was mostly unacceptable for competitive employment (40 50%)
3 Performance of task was barely acceptable for competitive employment (60-69%)
4 Performance of task was mostly acceptable for competitive employment (70-79%)
5 Performance of task was completely acceptable for competitive employment (80% and up)

Reported pain in lower back

Unable to continue due to poor stamina and
fatigue

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 12 of 23

9:10

Quality

% of task
completed

Engagement
Persistence in
participation of
task

(e.g. verbal,
grimace)

(e.g. head)

Day: 2 of 2

OBSERVATIONS AND COMMENTS

Other:

Performance

CLAIMANT REPORTED
SYMPTOMS
Expressio Location
n of Pain
of Pain

Fatigue

TASK
DESCRIPTION

ACTIVITY

Date: June 24, 2011

Dizzines

TIME

Duration of
Task (Mins)

SECTION 1: SYMPTOM AND ACTIVITY BEHAVIOUR CHART

Client arrived at
RTW

9:13
9:25

Mail Sort

12

100%

9:27
9:32

Alphabetizing

100%

9:32
9:38

Visual Maze

100%

Ingested extra oxycodone due to pain

Reported Feels tired and sore in back,
feels worse
Not eager to repeat testing from Day 1

Unable to stay on task.

9:40
9:43

Payroll
Computation

100%

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 13 of 23

Patient
Information
Memo

60%

9:54
9:56

Small Parts

50%

9:58
10:10

Small Parts
B 1 & B2

12

100

10:11
10:14

Ruler
Reading

100%

10:15
10:17

Pipe Assembly

100%

10:19
10:23

O-Rings

100%

Performance

Engagement

% of task
completed

Persistence in
participation of
task

(e.g. verbal,
grimace)

(e.g. head)

Sighing

Back

OBSERVATIONS AND COMMENTS

Other:

9:44
9:43

TASK
DESCRIPTION

Fatigue

Quality

TIME

CLAIMANT REPORTED
SYMPTOMS
Expressio Location
n of Pain
of Pain
Dizzines

Duration of
Task (Mins)

ACTIVITY

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 14 of 23

Block design

100%

10:31
10:32

Color Sort

100%

100%

16

100%

10:33
10:39

Performance

Engagement

% of task
completed

Persistence in
participation of
task

(e.g. verbal,
grimace)

(e.g. head)

OBSERVATIONS AND COMMENTS

Other:

10:28
10:29

TASK
DESCRIPTION

Fatigue

Quality

TIME

CLAIMANT REPORTED
SYMPTOMS
Expressio Location
n of Pain
of Pain
Dizzines

Duration of
Task (Mins)

ACTIVITY

Circuit Board

10:43
10:59

Assembling

Moaning

Back

11:05
11:45

Lunch

Task required reaching, squatting,

kneeing, using tools
Squatted on right knee, with left knee
flexed on floor
Reported soreness in back
Required to stand up and change
positions
Forward flexed to complete assembling
Reported pain due to crouching

40
Reported increased back pain

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 15 of 23

% of task
completed

Persistence in
participation of
task

100%

(e.g. verbal,
grimace)

(e.g. head)

OBSERVATIONS AND COMMENTS

Other:

32

Engagement

Fatigue

Quality

Performance

CLAIMANT REPORTED
SYMPTOMS
Expressio Location
n of Pain
of Pain
Dizzines

TASK
DESCRIPTION

Duration of
Task (Mins)

TIME

ACTIVITY

11:47
12:19

12:24
12:40
12:45

Sorting
(Screws)

Sorting
(Labels)

16

100%

Groaning
Moaning

Sighing

Back

Day two
finished

Rating of Activity Performance/Engagement:

1 Performance of task was completely unacceptable for employment (1-39%)
2 Performance of task was mostly unacceptable for competitive employment (40 50%)
3 Performance of task was barely acceptable for competitive employment (60-69%)
4 Performance of task was mostly acceptable for competitive employment (70-79%)
5 Performance of task was completely acceptable for competitive employment (80% and up)

Sorted 3 boxes of screws at just below

waist level
Required support to rest lower
extremities
Rested 4 times
Reported pain in back

Flexing neck/head caused headache

Increased back pain due to standing,
bending
Pain increased since the morning
Reported pain in lower back
Pain worse in back than yesterday
Poor stamina/tolerance indicated

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 16 of 23

SECTION 2 WORK BEHAVIOURS

Rating Scale:
1 Completely unacceptable for employment
2 Mostly unacceptable for competitive employment
3 Barely acceptable for competitive employment
4 Mostly acceptable for competitive employment
5 Completely acceptable for competitive employment

Work Behaviour

Following Directions
Communication
2-step instructions
Attention Span
Decision Making
Ability to Tolerate
Pressure
Interaction with CoWorkers
Interaction with
Supervisor
Breaks
Cooperation
Initiative
Motivation
Flexibility
Reaction to Repetitious
Work
Ability to Work
Independently
Ability to Accept
Criticism
Hygiene
Appearance

N Not applicable or observed

Comments
Requires repetition of directions with new tasks: on the second day client was
independent with commencement of tasks
No difficulty noted
No difficulty noted
Is able to focus attention on work
Able to make independent decisions
Aware of time restraints

Irritable, frustrated on the first day, also when performing repetitive tasks

Requires frequent work breaks due to pain and fatigue, every 10-15 minutes
Co-operates
Often takes initiative
Lack of motivation more marked on 2nd day
Difficulty with mental tasks e.g. reading and comprehending
Bored, reluctant to repeat tests

Needs to be encouraged to stay on track.

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 17 of 23

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 18 of 23

SECTION 3: METHOD-TIME-MEASUREMENT (MTM) WORK SAMPLE SUMMARY

Description:

Standardized work sample modules designed to assess a claimants

cognitive, affective and psychomotor abilities were administered. The
modules aid in assessing employability by providing insight into the
occupationally related skills that a claimant possesses or demonstrates. The
work sample modules provide a standardized assessment system, tied to
both Worker Qualification Profile factors (i.e. NOC linked through aptitude
levels) and to MTM industrial performance standards. The following
standardized work sample modules were administered.
STANDARDIZED
WORK SAMPLES
Mail Sort
Alphabetizing
Visual Maze
Payroll
Computation
Patient Information
Memo
Small Parts (A)
Small Parts (B)
Rule Reading
Pipe Assembly
O-Rings
Block Design
Colour Sort
Circuit Board

Main Performance Skill

Required
Visual Discrimination
Clerical/Verbal Sequencing
Visual Motor Coordination
Clerical Numerical
Perception
Follows Written Instructions
Fine Motor Coordination
Eye/Hand Coordination
Measurement Skill
Manual Dexterity
Form Perception
Spatial Perception
Colour Discrimination
Follows Diagrammed
Instructions

RESULTS:
The following table shows the MTM summary of clients work sample performance
Note: An 87.5% MTM Rate of Work score is the cutoff point for passing the work sample. MTM
standard represents the work rate that well-trained employees in typical industrial contexts would
be expected to maintain over the course of the eight-hour workday as they repeatedly performed
the work tasks.

Trial # 1

MTM%

Errors

Result

Mail Sort
Alphabetizing
Visual Maze
Payroll Comp
Patient Info Memo
Small Parts A
Small Parts B
Ruler Reading
Pipe Assembly

n/a
n/a
n/a
n/a
n/a

9
7
8
2
7

31
34

0
0

No score - error limit exceeded

No score - error limit exceeded
No score - error limit exceeded
No score - error limit exceeded
No score - error limit exceeded
Unable to complete.
Unable to complete.
MTM not met
MTM not met.

Name: Mr. XXX XXX

Date of Report: XXX XXX
Page 19 of 23

O-Rings
Block Design
Color Sort
Circuit Board

51
n/a
19
31

1
4
0
0

MTM not met.

No score - error limit exceeded
MTM not met.
MTM not met.

The following table shows the MTM summary of Mr. Smiths work sample performance on
trial #2 on the second day.
TRIAL # 2

MTM%

Errors

Result

Mail Sort
Alphabetizing
Visual Maze
Payroll Comp
Patient Info Memo
Small Parts A
Small Parts B
Ruler Reading
Pipe Assembly
O-Rings
Block Design
Color Sort
Circuit Board

n/a
n/a

7
6

n/a
n/a

2
5

n/a

68
n/a
19
31

0
1
0
0

No score - error limit exceeded

No score - error limit exceeded
Unable to complete
No score - error limit exceeded
No score - error limit exceeded
Unable to complete
Unable to complete
No score - error limit exceeded
Unable to complete
MTM not met.
No score - error limit exceeded
MTM not met.
MTM not met.

Mr. XXXX demonstrated a work rate below the competitive rate in all work samples that
he was able to complete. There was an increase in the number of work samples that he
was unable to complete in the second trial. Deficits in visual discrimination, clerical/verbal
sequencing, clerical/numerical perception, following written instructions and motor
coordination were apparent and these deficits significantly contributed to his poor overall
performance.
Based on the above, the following aptitude profile is compiled for Mr. XXXX:
Table 1 shows the derived claimants aptitude profile as demonstrated in the performance
of the standardized assessment modules.
Table 1
Code
G

Aptitude Description

Level

General Learning Ability: The ability to catch on or

understand instructions and underlying principles; the ability to
reason and make judgments. Closely related to doing well in
school.

Verbal Aptitude: The ability to understand meaning of words

and to use them effectively. The ability to comprehend
language, to understand relationships between words and to
understand meanings of whole sentences and paragraph.

Numerical Aptitude: Ability to perform arithmetic operations

quickly and accurately. Using numbers for calculations or