Form OWCP-5a, Work Capacity Evaluation Instructions
This form contains 23 fields organized into 9 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| 1. Competent to WORK 8 hours a day (answer and narrative) | ||
| Medical/narrative explanation for work capacity | Text |
Provide the detailed medical reasons, clinical findings, and explanation supporting the answer about the employee's ability to work eight hours per day. Fill only if 'Competent to work 8 hours — Answer' is 'No'.
Depends on:
Competent to work 8 hours — Answer
|
| Competent to work 8 hours — Answer | Combobox |
Enter the clinician's answer indicating whether the employee is competent to work an eight-hour day (e.g., Yes, No, or conditional statement); if 'No', medical reasons must be provided in the narrative field.
No
Yes
|
| 2. Hours able to work, increase (yes/no), when and narrative | ||
| Narrative — medical reasons | Text |
Provide a detailed narrative explaining the medical reasons and supporting opinion for why the employee cannot work an eight-hour day, including specific limitations, symptoms, and any relevant clinical findings. Fill only if 'Will hours increase — No indicator' is 'No'.
Depends on:
Will hours increase — No indicator
|
| Hours able to work per day | Text |
Enter the number of hours per workday the employee is currently able to perform (for example, 4 or 6). Fill only if 'Competent to work 8 hours — Answer' is 'No'.
Depends on:
Competent to work 8 hours — Answer
|
| Will hours increase — Yes indicator | Combobox |
Indicate that the number of hours is expected to increase by marking or entering 'Yes' in this box if an increase is anticipated. Fill only if 'Competent to work 8 hours — Answer' is 'No'.
Depends on:
Competent to work 8 hours — Answer
|
| Will hours increase — No indicator | Combobox |
Indicate that the number of hours is not expected to increase by marking or entering 'No' in this box if no increase is anticipated. Fill only if 'Competent to work 8 hours — Answer' is 'No'.
Depends on:
Competent to work 8 hours — Answer
|
| Expected date to return to eight-hour days | Date |
Provide the expected date when the employee will be able to work full eight-hour workdays. Fill only if 'Will hours increase — Yes indicator' is 'Yes'.
Depends on:
Will hours increase — Yes indicator
|
| 3. Competent to perform usual job (yes/no and narrative) | ||
| Usual Job Competency Narrative | Text |
Provide a detailed narrative explaining whether the worker can perform their usual job and, if not, specify which aspects of the position are problematic with supporting medical rationale. Fill only if 'Competent to Perform Usual Job — No' is 'No'.
Depends on:
Competent to Perform Usual Job — No
|
| Competent to Perform Usual Job — Yes | Combobox |
Enter 'Yes' (or a brief confirmation) to indicate the worker is competent to perform their usual job.
|
| Competent to Perform Usual Job — No | Combobox |
Enter 'No' (or a brief denial) to indicate the worker is not competent to perform their usual job.
|
| 4. Suitable duties/work environment (narrative) | ||
| Suitable duties / work environment (narrative) | Text |
Provide a detailed narrative describing the specific job duties, tasks, and work environment(s) that are suitable for the injured worker given their medical limitations.
|
| 5. Other medical factors (narrative) | ||
| Other medical factors (narrative) | Text |
List any additional medical factors that should be considered when identifying a suitable position for this person and provide a clear explanation for each item.
|
| 6. Physician's Name and Telephone | ||
| Physician Last Name | Text |
Type or print the physician's last name (surname) exactly as it should appear.
|
| Physician First Name | Text |
Type or print the physician's first (given) name.
|
| Physician Middle Name / Initial | Text |
Type or print the physician's middle name or initial (or professional suffix if applicable).
|
| Physician Telephone (Include Area Code) | Text |
Enter the physician's telephone number including area code (include any parentheses, dashes or spaces as needed).
|
| 9. Date | ||
| Date | Date |
Enter the date the physician signed or completed this form.
|
| Form Actions | ||
| Print form | Button |
Click this button to print the form.
|
| Reset form | Button |
Click this button to reset the form to its default state.
|
| Injured Worker's Name and OWCP No. | ||
| First Name | Text |
Enter the injured worker's first (given) name as it appears on official records.
|
| Middle Name / Initial | Text |
Enter the injured worker's middle name or middle initial, or leave blank if none.
|
| Last Name | Text |
Enter the injured worker's last name (family name/surname) as it appears on official records.
|
| OWCP Number | Text |
Enter the injured worker's Office of Workers' Compensation Programs (OWCP) claim or file number.
|