owcp-5b Work Capacity Evaluation

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U.S. Department of Labor

Work Capacity Evaluation
Cardiovascular/Pulmonary Conditions
Injured Worker's Name (First, middle, last)

*

Employment Standards Administration
Office of Workers' Compensation Programs
OMB No: 1215-0103

OWCP No. *

Expires: 10/31/2008
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, is prevention (of possible future injury)
Yes
1.a. Is this employee capable of performing his/her usual job?
the only reason for work limitations?
Yes
No. If prevention is not the only reason, please explain your medical reason
for limitations: *

Many employers can readily accommodate medical restrictions including assignment of the injured worker to an
alternative work location.
b. If unable to perform his/her usual job, is the employee able to work for 8 hours per workday with restrictions?
c. If less than 8 hours per workday, how many hours can he/she work?
d. Do You anticipate an increase in the number of hours this person will be able to work?
No
Yes
If yes, when will this person achieve an 8 hour workday?
If no, please provide medical reasons to support your opinion:
2. Has the work injury/condition caused ANATOMICAL and/or FUNCTIONAL changes in the cardiovascular or respiratory
systems that preclude exposure to: *
a. Temperature extremes
Yes
No
c. Gas/fumes
b. Airborne particles
Yes
No
d. Electromagnetic radiation

Yes
Yes

No
No

3. 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
Bending
Operating a
Motor Vehicle

Limitation
Yes
Yes
Yes
Yes
Yes

# of Hours
Able to Work

Yes

Activity
Pushing
Pulling
Lifting
Squatting
Kneeling
Climbing

4. Is the person taking MEDICATIONS that impact the ability to work? Please explain.

Limitation
Yes
Yes
Yes
Yes
Yes
Yes

# of Hours
Able to Work

Lbs.

*

5. Are there OTHER medical factors, situational considerations (e.g., high volume work, shifting priorities), equipment or devices which need to be considered
in the identification of a position for this person? If so, please explain.

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 THE OFFICE SHOWN ABOVE.

Form OWCP-5b
Rev October 2001

OWCP 5b:
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 cardiovascular or pulmonary 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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