Form OWCP-5a, Work Capacity Evaluation Instructions
This form contains 23 fields organized into 6 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Form Actions | ||
| Print form | Button |
Click this button to print the form.
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| Reset form | Button |
Click this button to reset the form to its default state.
|
| General Information | ||
| Enter date (mm/dd/yyyy) | Text |
Enter the date in the format mm/dd/yyyy.
|
| Medical Details | ||
| Please explain each item | Text |
Provide detailed explanations for each item mentioned in the form.
|
| If no, your medical reasons are required to support your opinion | Text |
If the patient is not able to work, provide the medical reasons supporting this opinion.
|
| Enter medical reasons | Text |
Enter the medical reasons for the patient's inability to work or any restrictions.
|
| Physician Information | ||
| Enter physician's first name | Text |
Enter the first name of the physician evaluating the worker.
|
| Enter physician's middle initial | Text |
Enter the middle initial of the physician evaluating the worker. This field accepts only one character.
|
| Enter physician's last name | Text |
Enter the last name of the physician evaluating the worker.
|
| Enter phone number | Text |
Enter the phone number of the physician evaluating the worker. The phone number should be in the format (XXX) XXX-XXXX.
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| Work Capacity | ||
| Describe the duties or work environments suitable for patient | Text |
Describe the types of duties or work environments that are suitable for the patient, considering their medical condition.
|
| If no, specify which aspects of the position are problematic. An explanation is required for each item | Text |
If the patient cannot perform their usual job, specify which aspects of the position are problematic and provide an explanation for each item.
|
| Is the employee competent to WORK 8 hours a day? Choose Yes/No | ComboBox |
Indicate whether the employee is competent to work 8 hours a day by choosing Yes or No.
No
Yes
|
| Enter number of hours | Text |
Enter the number of hours the employee is able to work per day.
|
| topmostSubform[0].Page1[0].radYN1_p1_3[0]_0 | ComboBox |
Select this radio button if the answer to the associated question is Yes.
|
| topmostSubform[0].Page1[0].radYN1_p1_3[0]_1 | ComboBox |
Select this radio button if the answer to the associated question is No.
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| If yes, when will this employee be able to work eight hour work days?(mm/dd/yyyy) | Text |
If the employee is able to work eight-hour workdays, specify the date when this will be possible in the format mm/dd/yyyy.
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| topmostSubform[0].Page1[0].radYN0_p1_yn_31[0]_0 | ComboBox |
Select 'Yes' if the worker is able to work full-time, otherwise select 'No'.
|
| topmostSubform[0].Page1[0].radYN0_p1_yn_31[0]_1 | ComboBox |
Select 'No' if the worker is not able to work full-time, otherwise select 'Yes'.
|
| Worker Information | ||
| Enter injured worker's first name | Text |
Enter the first name of the injured worker. Maximum length is 20 characters.
|
| Enter injured worker's middle initial | Text |
Enter the middle initial of the injured worker. Maximum length is 1 character.
|
| Enter injured worker's last name | Text |
Enter the last name of the injured worker. Maximum length is 20 characters.
|
| Enter OWCP file number | Text |
Enter the OWCP file number associated with the injured worker. Maximum length is 9 characters.
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