Form OWCP-5c, Work Capacity Evaluation Instructions
This form contains 81 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Activity Details | ||
| Duration | Text |
Specify the duration of the limitation or activity.
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| Frequency | Text |
Specify the frequency of the limitation or activity.
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| Duration | Text |
Specify the duration of the limitation or activity related to operating a vehicle.
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| Frequency | Text |
Specify the frequency of the limitation or activity related to operating a vehicle.
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| Activity Limitations | ||
| Check to select | CheckBox |
Check this box if there are limitations in sitting.
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| If there are limitations in sitting please provide the number of hours he is able to work(hh) | Text |
If there are limitations in sitting, provide the number of hours the worker is able to work (in hours).
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| Check to select | CheckBox |
Check this box if there are limitations in walking.
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| If there are limitations in walking please provide the number of hours he is able to work(hh) | Text |
If there are limitations in walking, provide the number of hours the worker is able to work (in hours).
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| Check to select | CheckBox |
Check this box if there are limitations in standing.
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| Check to select | CheckBox |
Check this box if there are limitations in working.
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| If there are limitations in standing please provide the number of hours he is able to work(hh) | Text |
If there are limitations in standing, provide the number of hours the worker is able to work (in hours).
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| Additional Information | ||
| 3. If there are OTHER medical facts, situational factors, equipment or devices which need to be considered in the identification of a position for this person, please explain in a narrative report | Text |
Provide any other medical facts, situational factors, equipment, or devices that need to be considered in a narrative report.
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| Form Controls | ||
| Reset form | Button |
Click this button to reset the form to its default state.
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| Print form | Button |
Click this button to print the form.
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| Job Capability | ||
| topmostSubform[0].Page1[0].radYN0_p1_yn_1a[0]_0 | ComboBox |
Select 'Yes' if the worker is capable of performing their usual job.
|
| topmostSubform[0].Page1[0].radYN0_p1_yn_1a[0]_1 | ComboBox |
Select 'No' if the worker is not capable of performing their usual job.
|
| Is the worker capable of performing his/her usual job? if no, explain | Text |
If the worker is not capable of performing their usual job, explain the reasons.
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| topmostSubform[0].Page1[0].radYN0_p1_yn_1b[0]_0 | ComboBox |
Select 'Yes' if the worker can perform other work.
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| topmostSubform[0].Page1[0].radYN0_p1_yn_1b[0]_1 | ComboBox |
Select 'No' if the worker cannot perform other work.
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| C. If less that 8 hour per workday, how many can he/she work | Text |
If the worker can work less than 8 hours per workday, specify the number of hours they can work.
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| topmostSubform[0].Page1[0].radYN0_p1_yn_1d[0]_0 | ComboBox |
Select 'Yes' if the worker can perform their usual job. Otherwise, select 'No'.
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| topmostSubform[0].Page1[0].radYN0_p1_yn_1d[0]_1 | ComboBox |
Select 'No' if the worker cannot perform their usual job. Otherwise, select 'Yes'.
|
| Medical Information | ||
| Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation Programs (OWCP) has accepted the following conditions | Text |
Provide details about the conditions accepted by the Office of Workers' Compensation Programs (OWCP) for the injured worker.
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| If no, please provide medical reasons to support your opinion | Text |
If the worker cannot perform other work, provide medical reasons to support this opinion.
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| Medical Justification | ||
| If no, please provide medical reasons to support your opinion in a narrative report | Text |
If the worker cannot perform their usual job, provide medical reasons to support your opinion in a narrative report.
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| Medical Restrictions | ||
| Enter how long restrictions apply | Text |
Enter the duration for which the medical restrictions apply.
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| Physical Capabilities | ||
| topmostSubform[0].Page1[0].radYN0_yn_2a_sedentary[0]_0 | ComboBox |
Select this option if the worker is capable of performing sedentary work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_sedentary[0]_1 | ComboBox |
Select this option if the worker is not capable of performing sedentary work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_light[0]_0 | ComboBox |
Select this option if the worker is capable of performing light work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_light[0]_1 | ComboBox |
Select this option if the worker is not capable of performing light work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_veryheavy[0]_0 | ComboBox |
Select this option if the worker is capable of performing very heavy work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_veryheavy[0]_1 | ComboBox |
Select this option if the worker is not capable of performing very heavy work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_heavy[0]_0 | ComboBox |
Select this option if the worker is capable of performing heavy work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_heavy[0]_1 | ComboBox |
Select this option if the worker is not capable of performing heavy work.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_medium[0]_0 | ComboBox |
Indicate whether the worker can perform the specified medium-level activity. Select 'Yes' if the worker can perform the activity, otherwise select 'No'.
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| topmostSubform[0].Page1[0].radYN0_yn_2a_medium[0]_1 | ComboBox |
Indicate whether the worker can perform the specified medium-level activity. Select 'Yes' if the worker can perform the activity, otherwise select 'No'.
|
| Physical Limitations | ||
| topmostSubform[0].Page1[0].radYN0_p1_yn_1g[0]_0 | ComboBox |
Select 'Yes' if the worker has any physical limitations. Otherwise, select 'No'.
|
| topmostSubform[0].Page1[0].radYN0_p1_yn_1g[0]_1 | ComboBox |
Select 'No' if the worker does not have any physical limitations. Otherwise, select 'Yes'.
|
| Check to select | CheckBox |
Select this checkbox if there are limitations in moving wrists.
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| If there are limitations in moving wrists please provide the number of hours he is able to work(hh) | Text |
Provide the number of hours the worker is able to work if there are limitations in moving wrists.
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| If there are limitations in reaching please provide the number of hours he is able to work(hh) | Text |
Provide the number of hours the worker is able to work if there are limitations in reaching.
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| Check to select | CheckBox |
Select this checkbox if there are limitations in moving elbows.
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| If there are limitations in moving elbow please provide the number of hours he is able to work(hh) | Text |
Provide the number of hours the worker is able to work if there are limitations in moving elbows.
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| Check to select | CheckBox |
Select this checkbox if there are limitations in pushing.
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| If there are limitations in pushing please provide the number of hours he is able to work(hh) | Text |
Provide the number of hours the worker is able to work if there are limitations in pushing.
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| If there are limitations in pushing please provide the maximum number of pounds that can be handled by this person. (lbs) | Text |
Provide the maximum number of pounds that can be handled by the worker if there are limitations in pushing.
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| Check to select | CheckBox |
Select this checkbox if there are limitations in reaching above shoulder.
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| If there are limitations in reaching above shoulder please provide the number of hours he is able to work(hh) | Text |
Provide the number of hours the worker is able to work if there are limitations in reaching above shoulder.
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| Check to select | CheckBox |
Select this checkbox if there are limitations in pulling.
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| If there are limitations in pulling please provide the number of hours he is able to work(hh) | Text |
Provide the number of hours the worker is able to work if there are limitations in pulling.
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| If there are limitations in pulling please provide the maximum number of pounds that can be handled by this person. (lbs) | Text |
Provide the maximum number of pounds that can be handled by the worker if there are limitations in pulling.
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| Check to select | CheckBox |
Select this checkbox if there are limitations in twisting.
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| If there are limitations in twisting please provide the number of hours he is able to work(hh) | Text |
Specify the number of hours the injured worker is able to work if there are limitations in twisting.
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| Check to select | CheckBox |
Check this box if there are limitations in twisting.
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| If there are limitations in lifting please provide the number of hours he is able to work(hh) | Text |
Specify the number of hours the injured worker is able to work if there are limitations in lifting.
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| If there are limitations in lifting please provide the maximum number of pounds that can be handled by this person. (lbs) | Text |
Specify the maximum number of pounds the injured worker can lift if there are limitations in lifting.
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| Check to select | CheckBox |
Check this box if there are limitations in lifting.
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| If there are limitations in bending/stooping please provide the number of hours he is able to work(hh) | Text |
Specify the number of hours the injured worker is able to work if there are limitations in bending/stooping.
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| Check to select | CheckBox |
Check this box if there are limitations in bending/stooping.
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| If there are limitations in squatting please provide the number of hours he is able to work(hh) | Text |
Specify the number of hours the injured worker is able to work if there are limitations in squatting.
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| If there are limitations in squatting please provide the maximum number of pounds that can be handled by this person. (lbs) | Text |
Specify the maximum number of pounds the injured worker can handle if there are limitations in squatting.
|
| Check to select | CheckBox |
Check this box if there are limitations in squatting.
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| If there are limitations in kneeling please provide the number of hours he is able to work(hh) | Text |
Specify the number of hours the injured worker is able to work if there are limitations in kneeling.
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| If there are limitations in kneeling please provide the maximum number of pounds that can be handled by this person. (lbs) | Text |
Specify the maximum number of pounds the injured worker can handle if there are limitations in kneeling.
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| Check to select | CheckBox |
Check this box if there are limitations in kneeling.
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| If there are limitations in operating vehicle please provide the number of hours he is able to work(hh) | Text |
Specify the number of hours the injured worker is able to work if there are limitations in operating a vehicle.
|
| Check to select | CheckBox |
Check this box if there are any limitations in climbing.
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| If there are limitations in climbing please provide the number of hours he is able to work(hh) | Text |
Enter the number of hours the worker is able to work if there are limitations in climbing.
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| If there are limitations in climbing please provide the maximum number of pounds that can be handled by this person. (lbs) | Text |
Enter the maximum number of pounds the worker can handle if there are limitations in climbing.
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| Check to select | CheckBox |
Check this box if there are any limitations in operating a vehicle to/from work.
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| If there are limitations in operating vehicle to/from work please provide the number of hours he is able to work(hh) | Text |
Enter the number of hours the worker is able to work if there are limitations in operating a vehicle to/from work.
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| Physician Information | ||
| 4. Physician's Name (Type or print) | Text |
Enter the physician's first name (type or print).
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| 34cb | Text |
Enter the physician's middle initial.
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| Enter Physician's Last Name | Text |
Enter the physician's last name.
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| 5. Telephone Number (Include Area Code) | Text |
Enter the physician's telephone number, including the area code.
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| 7. Date | Text |
Enter the date of the evaluation.
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| Work Capacity | ||
| If yes, when will this person achieve an 8 hour workday? e | Text |
If the worker is expected to achieve an 8-hour workday, specify the estimated date.
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| Worker Information | ||
| Injured Worker's Name ( First, middle, last) | Text |
Enter the injured worker's full name, including first, middle, and last names.
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| 525d | Text |
Enter the middle initial of the injured worker's name.
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| 525d a | Text |
Enter the last name of the injured worker.
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| OWCP No | Text |
Enter the Office of Workers' Compensation Programs (OWCP) number assigned to the injured worker.
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