owcp-5c Work Capacity Evaluation Form, Musculoskeletal Condition

Work Capacity Evaluation
Musculoskeletal Conditions

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

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

OMB No:
Expires:

1240-0046
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:

1a. Is the worker capable of performing his/her
usual job without restriction?

Yes

No

If no, please provide medical reasons to support your opinion in a narrative report.

Many employers can readily accommodate medical restrictions including modified duty assignment(s) or
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
physical restrictions?
If no, please provide medical reasons to support your opinion in a narrative report.
Yes
No

c.

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

d.

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

e.

If yes, when will this person achieve an 8 hour workday?

Yes

No

If no, please provide medical reasons to support your opinion in a narrative report.

f.

How long will the restrictions apply?

g.

Has maximum medical improvement been reached?

Yes

No

2a. Please review the Guidance for Physicians included on pages 2 and 3 of this form. Based on the parameters provided, please indicate whether this person
is capable of working within any of the following Strength Levels:
Sedentary

Yes

No

Light

Yes

No

Medium

Yes

No

Heavy

Yes

Very Heavy

No

2b. If not, 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
Activity
Limitation
Able to Work
Activity
Limitation
Sitting
Walking
Standing
Reaching
Reaching above

Yes
Yes
Yes
Yes

Shoulder
Twisting
Bending/Stooping
Operating Motor Vehicle
at work

Yes
Yes
Yes

Operating a Motor Vehicle
to/from work

Yes
Yes

# of Hours
Able to Work

Yes

No

Lbs.

Repetitive Movements:
Wrists
Elbow

Yes
Yes

Pushing
Pulling
Lifting
Squatting
Kneeling
Climbing
Breaks:
Duration
Duration

Yes
Yes
Yes
Yes
Yes
Yes
Frequency
Frequency

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

4. Physician's Name (Type or print)

5. Telephone Number
(Include Area Code)

6. Signature

7. Date
OWCP-5c (Rev. 08-14)

Physical Demand Definitions for the OWCP
OWCP has adopted the following Strength Level definitions to indicate the absence or presence and frequency
of the physical demand components requested on the OWCP-5b and OWCP-5c.
1. STRENGTH LEVEL
Sedentary Work
Sedentary Work involves exerting up to 10 pounds of force occasionally or a negligible amount of force
frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work
involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs may be
defined as Sedentary when walking and standing are required only occasionally and all other Sedentary
criteria are met.
Light Work
Light Work involves exerting up to 20 pounds of force occasionally or up to 10 pounds of force frequently, or a
negligible amount of force constantly to move objects. Physical demand requirements are in excess of those
for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job/occupation is rated
Light Work when it requires: (1) walking or standing to a significant degree; (2) sitting most of the time while
pushing or pulling arm or leg controls; or (3) working at a production rate pace while constantly pushing or
pulling materials even though the weight of the materials is negligible. (The constant stress and strain of
maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a
worker even though the amount of force exerted is negligible.)
Medium Work
Medium Work involves exerting 20 to 50 pounds of force occasionally or 10 to 25 pounds of force frequently
or an amount greater than negligible and up to 10 pounds constantly to move objects. Physical demand
requirements are in excess of these for Light Work.
Heavy Work
Heavy Work involves exerting 50 to 100 pounds of force occasionally, or 25 to 50 pounds of force frequently,
or 10 to 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those
for Medium Work.
Very Heavy Work
Very Heavy work involves exerting in excess of 100 pounds of force occasionally, or in excess of 50 pounds
of force frequently or in excess of 20 pounds of force constantly to move objects, Physical demand
requirements are in excess of those for Heavy Work.

LIMITS OF WEIGHTS LIFTED/CARRIED/PUSHED/PULLED
Rating

Occasionally

Sedentary
* - 10
Light
* - 20
Medium
20 - 50
Heavy
50 - 100
Very Heavy
100 +
* = negligible weight; N/A = Not Applicable

Frequently

Constantly

*
* - 10
10 - 25
25 - 50
50 +

N/A
*
* - 10
10 - 20
20 +

The range excludes the lower number and includes the higher number, i.e., the range 10 - 25 excludes 10
(begins at 10 +) and includes 25.

OWCP-5c PAGE 2 (Rev. 08-14)

Physical Demand Definitions for the OWCP (continued)
PRESENCE AND/OR FREQUENCY OF OTHER PHYSICAL DEMANDS
The following codes and definitions indicate the absence or presence and frequency of other Physical
Demand components requested on the OWCP-5b and OWCP-5c.
Code

Frequency

Definition

Max # hrs./8-hr. day

N
O
F
C

Not Present
Occasionally
Frequently
Constantly

Activity/condition does not exist.
Activity/condition exists up to 1/3 of the time.
Activity/condition exists from 1/3 to 2/3 of the time.
Activity/condition exists 2/3 or more of the time.

0
2 hrs. 40 min.
5 hrs. 20 min.
8

2. REACHING
Forward flexion and/or abduction of the hand(s) and arm(s); generally, within a 0◦ - 90◦ range of motion from
the shoulder; or extension within a 0◦ - 50 ◦ range of motion from the shoulder.
3. REACHING ABOVE THE SHOULDER
Forward flexion and/or abduction of the hand(s) and arm(s); generally at greater than 90◦ from the shoulder.
4. TWISTING
Turning, twisting, contorting, or flexing the torso in any direction towards the right or left.
5. BENDING/STOOPING
Bending body downward and forward by bending spine at the waist requiring full use of the lower extremities
and back muscles.
6. OPERATING A MOTOR VEHICLE AT WORK
Driving any vehicle during the performance of one's duties.
7. REPETITIVE MOVEMENTS OF ELBOWS (HANDLING)
Seizing, holding, grasping, turning, or otherwise working with hand or hands using the whole arm.
8. REPETITIVE MOVEMENTS OF WRISTS (FINGERING)
Picking, pinching, or otherwise working primarily with fingers and wrists rather than the whole arm as in
handling.
9. SQUATTING (CROUCHING)
Bending body downward and forward by bending legs and spine.
10. KNEELING
Bending legs at knees to come to rest on knee or knees.
11. CLIMBING
Ascending or descending ladders, stair, scaffolding, ramps, poles, and the like, using feet and legs or hands
and arms. Body agility is emphasized.

OWCP-5c PAGE 3 (Rev. 08-14)

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 musculoskeletal 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 OWCP in the form of communication
assistance, accommodation and modification to aid you in the 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-5c PAGE 4 (Rev. 08-14)