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.
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 |
