OWCP-5A Work Capacity Evaluation

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U.S. Department of Labor

Work Capacity Evaluation
Psychiatric/Psychological Conditions

Employment Standards Administration
Office of Workers' Compensation Programs

Injured Worker's Name (First, middle, last) *

OMB No: 1215-0103
Expires: 10/31/2008

OWCP No. *

Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation
Programs (OWCP) has accepted the following conditions as caused or aggravated by work:
1. Is the employee competent to WORK 8 hours a day?
*
opinion.

If no, your medical reasons are required to support your

2. If the employee is unable to work 8 hours a day, how many hours is he/she able to work?
a. Will the number of hours increase?
Yes
No
b. If yes, when will this employee be able to work eight hour work days?
c. If no, your medical reasons are required to support your opinion.

3. Is the worker competent to perform his/her usual job?
problematic. An explanation is required for each item. *

Yes

No

If no, specify which aspects of the position are

4. OWCP is committed to reemploying injured workers to the fullest extent possible. Many employers can readily
accommodate medical restrictions including assignment of the injured worker into an alternative work location.
Please note that if reemployment at the employing agency is not possible, the Office may pursue vocational
rehabilitation for the injured worker. With this in mind, please describe the duties or work environment(s) which are
suitable for your patient. Please be as detailed as possible. *

5. Please list, if any, other medical factors which need to be considered in the identification of a position for this person.
Please explain each item.

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

7. Telephone *

Signature

9. 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 THIS OFFICE

Form OWCP-5a
Rev. October 2001

OWCP 5a:
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 where the accepted
condition is psychiatric or psychological 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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