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Cognitive symptoms at work checklist

Modified from: Ottati A, Feuerstein M. Brief self-report measure of work-related cognitive limitations in breast cancer survivors. J Cancer Surviv. 2013 Jun;7(2):262-73. doi: 10.1007/s11764-013-0275-9. Epub 2013 Apr 4.

Instructions: If there are concerns whether cognitive challenges may affect your ability to successfully return or stay at work in a safe, productive, and competitive way, completing this tool and showing the results can inform a discussion between relevant parties (patient, healthcare provider, employer, and insurance provider). This tool has been validated in those actively working. However, your answers may also help those anticipating your return to work to identify, anticipate and address challenges.

In step 1, you say yes or no to the sample of cognitive challenges questions.

In step 2, you will be prompted to rate the level of difficulty for each question answered yes.  

Are you already back to work, or planning to go back?


Step 2: Rate the difficultly of each of the following:

1 = Very low
2 = Low
3 = Moderate
4 = High
5 = Very high

Difficulty Problem

Please complete the chart, then press Done to continue.

You're doing great!

Since you did not identify any cognitive challenges that you are currently facing, you do not need to complete step 2.

Done! Here are your results:

The scores below give you an idea of which tasks you have said gives you the most difficulty. Keep an eye on these and try to work on them or think about getting some help from co-workers, supervisor or professional counselor, especially if these concerns interfere with your ability to get work done in the way you or your workplace expects.