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Interactive Tools Cognitive symptoms at work checklist

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: Filling out this tool and sharing your responses with the appropriate parties (patients, healthcare providers, employers, and insurance companies) can help facilitate a productive discussion about ways to adapt and improve your cognitive functions, if you have concerns about your cognitive functions (ability to think) or whether cognitive challenges will affect your ability to return to or remain at work in a safe, productive, and competitive manner. Although this tool has been validated for those who are currently back at work after cancer, your responses may also be used to identify and foresee potential difficulties you might experience once you resume employment.

Step 1 involves answering yes or no to a series of questions about cognitive challenges.

Step 2 involves rating the degree of difficulty for each question that you answered yes to in Step 1. 

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.