Cc-Form-5 - Physician'S Report On Release And Restrictions
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1CC-FORM-5
WORKERS’ COMPENSATION COMMISSION
Revised 2 - 2 - 16
1915 NORTH STILES AVENUE STE 231
THIS SPACE FOR COMMISSION USE ONLY
SEND COPIES TO:
OKLAHOMA CITY, OK 73105
1- Employee/Claimant
1 - All Other Parties of Record
PHYSICIAN’S REPORT ON RELEASE AND RESTRICTIONS
In re claim of:
Full Name of Employee (Claimant)
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
COMMISSION FILE NO.
Name of Employer (Respondent)
Diagnosis
Date of Injury
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk
Group, Uninsured
Part of Body
Date of Exam
YES, released to:
Regular Work (date):
Modified Work (date):
Give Restrictions (complete Section II)
RELEASED
FOR
I.
NO, claimant remains temporarily totally disabled.
WORK?
RESTRICTIONS (check all that apply and describe fully under number 8 below)
II.
No Restrictions
Permanent Restrictions
Temporary Restrictions
1.___Restricted lifting (maximum weight in pounds) 10___ 25___ 50___ Other____
Frequency ___________
2.___Restricted pushing/pulling of _________ lbs.
3.___Restricted reaching:
above chest
overhead
away from body
4.___Restricted to one-handed duty. No use of:
Right hand
Left hand
5.___Restricted
walking
standing
sitting (describe fully)
partial weight bearing (describe fully)
bending
twisting
6.___Wear splint at:
All Times
Work
Night (describe fully)
7.___DO NOT:
Operate Machinery
Crawl
Kneel
Squat
Drive any Vehicle
Climb
Bend
Stoop
Twist
8.
FULLY DESCRIBE RESTRICTIONS (i.e. duration, nature of limitation, etc.) Supplement with extra pages if needed:
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
MEDICAL & REHABILITATION
III.
A.
Is continuing medical maintenance needed? NO
YES
If YES, describe fully, including date of next appointment. Supplement with extra
pages if needed.
B.
Is vocational rehabilitation indicated? (i.e. As a result of the injury, is the employee unable to perform work for which the person has previous
training or experience?) NO
YES
I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true,
correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a
fine or both.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee/Counsel
Signed this ________day of________________________________, _________.
Address (Number & Street)
Signature of Physician
City
State
Zip Code
Address (Number & Street)
Employer/Counsel
City
State
Zip Code
Address (Number & Street)
Telephone Number of Physician
City
State
Zip Code
Print or type name of Physician
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