Form Owcp-5b - Work Capacity Evaluation Cardiovascular Pulmonary Conditions - U.s. Department Of Labor, Office Of Workers' Compensation Programs Page 2
Download a blank fillable Form Owcp-5b - Work Capacity Evaluation Cardiovascular Pulmonary Conditions - U.s. Department Of Labor, Office Of Workers' Compensation Programs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Owcp-5b - Work Capacity Evaluation Cardiovascular Pulmonary Conditions - U.s. Department Of Labor, Office Of Workers' Compensation Programs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Privacy 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 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-5b PAGE 2 (Rev. 05-11)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Eta 9058 - Certification Workload And Characteristics Of Certified Individuals Work Opportunity And Welfare-to-work Tax Credits - Report No. 2 - U.s.department Of Labor
Legal
Form Eta 9059 - Verification Results Work Opportunity And Welfare-to-work Tax Credits - Report No. 3 - U.s.department Of Labor
Legal
Form Hud-21019 - Hud Headquarters Library Retained Loan Request - U.s. Department Of Housing And Urban Development
Legal
Form Hud-304 - Adjustment Report - Monthly Production Report Template - U.s. Department Of Housing And Urban Development
Legal
Form Hud-56002 - Completion Certificate For Property Improvements Template - U.s. Department Of Housing And Urban Development
Legal
Form Ee-1 - Worker's Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - U.s. Department Of Labor, Office Of Workers' Compensation Programs
Legal
Related Categories
Parent category: Legal