Form Owcp-5b - Work Capacity Evaluation Cardiovascular Pulmonary Conditions - U.s. Department Of Labor, Office Of Workers' Compensation Programs

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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

the only reason for work limitations?

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

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

b. Airborne particles

d. Electromagnetic radiation

Yes

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

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)