owcp-5c Work Capacity Evaluation Form

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U.S. Department of Labor

Work Capacity Evaluation
Musculoskeletal Conditions
Injured Worker's Name (First, middle, last)

Employment Standards Administration
Office of Workers' Compensation Programs

*

*

OWCP No.

1215-0103
10-31-2008

OMB No:
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:

1a. Is the worker capable of performing his/her usual job?

*

No. If no, please explain.

Yes

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

d.
e.

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

f.

How long will the restrictions apply?

g.

Has maximum medical improvement been reached?

c.

*

Yes

No

No.

2. 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.

Activity
Sitting
Walking
Standing
Reaching
Reaching above

Limitation
Yes
Yes
Yes
Yes

Shoulder
Twisting
Bending/Stooping
Operating Motor Vehicle
at work
Operating a Motor Vehicle
to/from work

# of Hours
Able to Work

Activity
Repetitive Movements:
Wrists
Elbow

Yes

Yes

Lbs.

Yes
Yes

Pushing
Pulling
Lifting
Squatting
Kneeling
Climbing
Breaks:
Duration
Duration

Yes
Yes
Yes

# of Hours
Able to Work

Limitation

Yes
Yes
Yes
Yes
Yes
Yes
Frequency
Frequency

3. 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.
4. Physician's Name (Type or print)
6. Signature *

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5. Telephone

Signature

7. Date

*

*

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

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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