Form OWCP-5a, Work Capacity Evaluation Completed Form Examples and Samples

Explore a detailed example of the OWCP-5a form, showcasing a completed Work Capacity Evaluation for an injured worker. This filled form includes essential information such as the employee's details, medical condition, evaluation date, and recommended work restrictions, providing a reliable reference for healthcare providers.
Form OWCP-5a, Work Capacity Evaluation has a basic Form Complexity Index of 40/100 — Instafill’s AI completes it in under a minute.
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Completed OWCP-5a Form for an injured worker's capacity evaluation

OWCP-5a Example – Work Capacity Evaluation for Injured Worker

How this form was filled:

This example shows a completed Form OWCP-5a for an injured employee. Key details include the employee's name, occupational injury specifics, medical assessment, and recommended work restrictions. The form is filled with recent dates and signed by a qualified medical professional.

Information used to fill out the document:

  • Employee Name: Jane Smith
  • Date of Injury: 02/10/2025
  • Claim Number: OWCP-123456
  • Medical Condition: Lower back strain
  • Treating Physician: Dr. Emily Brown
  • Evaluation Date: 03/20/2025
  • Recommended Work Restrictions: No lifting over 10 lbs, avoid prolonged standing
  • Signature: Dr. Emily Brown
  • Date Signed: 03/21/2025

What this filled form sample shows:

  • Detailed completion of employee information and injury particulars
  • Accurate medical condition description
  • Clear work restrictions based on medical evaluation
  • Properly documented signature and date by the medical professional

Form specifications and details:

Use Case: Evaluation of work capacity for an injured worker
Form Title: Form OWCP-5a - Work Capacity Evaluation
Purpose: Determine the injured employee's work capability and restrictions
Categories: OWCP forms
Completed OWCP-5a Form for an injured worker's capacity evaluation