CWES Assessment - Physical and Mental Capacities Questionnaires

The “Physical Capacities Questionnaire” (CW 61A) and the “Mental Capacities Questionnaire” (CW 61B) are used ONLY by the AC when it has been noted, and/or the AC suspects, the client is employable with limitations.

The purpose of these supplements is to determine the CWES client’s ability to do work-related activities on a daily basis in a regular work setting. These activities need to be approved CWES WTW activities.

The CW 61A and CW 61B are used ONLY as supplements to the CW 61.

Use of the CW 61A and CW 61B

The CW 61A and the CW 61B are used when:

• The previously obtained “Authorization to Release Medical Information” (CW 61) from the treating physician or licensed health care professional was determined to be insufficient for the development of an WTW 2, and/or
• The client recently self-disclosed physical and/or mental/emotional conditions that might interfere with the client’s ability to obtain employment.

Questionnaire Issuance

After reviewing the CW 61 and determining that additional information is needed to facilitate the development of an WTW 2, the CWES AC will issue the appropriate supplement(s) to the CWES client.

Time Frames

A CWES client has up to 30-calendar days to return the appropriate supplement(s): the CW 61A and/or CW 61B.

Note: If the supplement is incomplete, the AC may follow up by telephone with the treating physician. If the supplement(s) are not returned, the AC will explore alternatives such as getting a County Health Evaluation or a Department of Rehabilitation referral.

Form Completion CW 61A or CW 61B

When completing the CW 61A and the CW 61B, the AC must make the following entries on the top portion of the form:

• The date of issuance
• The patient’s name
• The patient’s Social Security number
• The case name and number.

The AC also must give a description of the nature and number of hours the client is assigned to the CWES activity.

The provider completes questions 1-9 on the CW 61A and questions 1-4 on the CW 61B. The CW 61A and CW 61B MUST be signed by a provider or an authorized representative of the provider to be valid.

Referral Procedures

If a client reports a previously undisclosed or newly acquired mental, emotional, physical, or medical condition that may negatively impact that individual’s ability to obtain and/or retain employment, use the following chart to determine appropriate action: