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U.S. Department of Labor
Work Capacity Evaluation
Cardiovascular/Pulmonary Conditions
Office of Workers' Compensation Programs
OMB No: 1240-0046
Injured Worker's Name ( First, middle, last )
OWCP No.
Expires: 10-31-2014
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?
If no, is prevention (of possible future injury)
Yes
No
the only reason for work limitations?
If prevention is not the only reason, please explain your medical reason
Yes
No
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
Yes
No
b. Airborne particles
d. Electromagnetic radiation
Yes
No
Yes
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.
# of Hours
# of Hours
Activity
Limitation
Able to Work
Activity
Limitation
Able to Work
Lbs.
Sitting
Yes
Pushing
Yes
Walking
Yes
Pulling
Yes
Standing
Yes
Lifting
Yes
Reaching
Yes
Squatting
Yes
Bending
Yes
Kneeling
Yes
Operating a
Climbing
Yes
Motor Vehicle
Yes
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)