OWCP-5c.pdf

ME-OW

U.S. Department of LaborWork Capacity Evaluation Musculoskeletal Conditions Employment Standards Administration

Office of Workers' Compensation Programs 1215-0103OWCP No. OMB No:Injured Worker's Name (First, middle, last)

10-31-2008 Expires:

Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation

Programs (OWCP) has accepted the following conditions:

No. If no, please explain.1a. Is the worker capable of performing his/her usual job? Yes

Many employers can readily accommodate medical restrictions including assignment of the injured worker into an alternative work location.

If the claimant is unable to perform his her usual job, is the claimant able to work for 8 hours per workday with restrictions? Yes No. If no, please provide medical reasons to support your opinion.

If less that 8 hour per workday, how many can he/she work?

NoYes Do you anticipate an increase in the number of hours this person will be able to work?

If yes, when will this person achieve an 8 hour workday? If no, please provide medical reasons to support your opinion

How long will the restrictions apply?f.

Yes No.Has maximum medical improvement been reached?

Please indicate whether this person has any LIMITATION in the activity listed and how many hours this person can perform each activity. If there are limitations in lifting, pulling and/or pushing, please provide the maximum number of pounds that can be handled by this person.

# of Hours # of Hours Activity Limitation Able to Work Lbs.Activity Limitation Able to Work Sitting Yes

Repetitive Movements:YesWalking YesWristsYesStanding

Elbow YesYesReaching Reaching above YesPushing

Shoulder Yes YesPulling YesTwisting YesLifting YesBending/Stooping YesSquatting

Operating Motor Vehicle YesKneeling at work Yes YesClimbing

Breaks:Operating a Motor Vehicle Duration Frequencyto/from work Yes Duration Frequency

Are there OTHER medical facts, situational factors, equipment or devices which need to be considered in the identification of a position for this person? If so, please explain.

The information requested will assist OWCP in determining eligibility to benefits and is required to obtain or retain a benefit. (5 USC 8101 et. seq.)

Public Burden Statement

We estimate that it will take an average of 15 minutes per response to complete this information collection including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE. Form OWCP-5c

Rev October 2001 b.

c.

d.

e.

g.

3.

2.

4. Physician's Name (Type or print) 5. Telephone

6. Signature 7. Date

OWCP 5c:

PRIVACY ACT

“NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is Section 8101, et seq., Title 5 of the U.S.

Code authorizes collection of this information. Completion of this form is required for the claimant to obtain or retain a benefit under 5 U.S.C. 8101 et seq. The information is used to obtain the claimant’s specific work tolerance limitations where the accepted condition is musculoskeletal in nature. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”

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