owcp-5b Work Capacity Evaluation

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

ME-OW

U.S. Department of Labor
Office of Workers' Compensation Programs
OWCP No. *

OMB No: 1240-0046
Expires: XX-XX-XXXX

Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation Programs (OWCP) has
accepted the following conditions:

✲❁❄❉❏

1.a. Is this employee capable of performing his/her usual job?
No If no, is prevention (of possible future injury)
Yes
the only reason for work limitations?
No If prevention is not the only reason, please explain your medical reason
Yes
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?
Yes
No
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
c. Gas/fumes
Yes
No
b. Airborne particles
d. Electromagnetic radiation
Yes
No

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
Yes

# of Hours
Able to Work

Activity
Pushing
Pulling
Lifting
Squatting
Kneeling
Climbing

Limitation
Yes
Yes
Yes
Yes
Yes
Yes

# of Hours
Able to Work

Lbs.

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

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 ) *

7. Telephone Number (Include Area Code) *

8. Signature

9. Date *

*

OWCP-5b (Rev. 05-11)

Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation
Act, as amended and extended (5 U.S.C. 8101, et seq.), authorizes collection of this information.
The purpose of this form is to obtain the claimant’s specific work tolerance limitation where the
accepted condition is cardiovascular/pulmonary in nature. Completion of this form is voluntary (5
U.S.C. 8101, et seq), however, failure to provide the information may result in the delay of
processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced
levels of benefits. 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.

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this
collection of information unless it displays a currently valid OMB control number. Public reporting
burden for this collection of information is estimated to average 15 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The obligation to respond to
this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et, seq. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers'
Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210,
and reference the OMB Control Number 1240-0046. Note: Please do not return the requested
information to the address shown just above. Rather, send it to the address shown on the
letterhead.

Notice
If you have a substantially limiting physical or mental impairment, Federal disability
nondiscrimination law gives you the right to receive help from DFEC in the form of communication
assistance, accommodation and modification to aid you in the FECA claims process. For example,
we will provide you with copies of documents in alternate formats, communication services such as
sign language interpretation, or other kinds of adjustments or changes to account for the limitations
of your disability. Please contact our office or the claims examiner to ask about this assistance.

OWCP-5b PAGE 2 (Rev. 05-11)