Fillable CC-FORM-5 PHYSICIANS REPORT ON RELEASE AND RESTRICTIONS Revised (Oklahoma)

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CC-FORM-5 PHYSICIANS REPORT ON RELEASE AND RESTRICTIONS Revised (Oklahoma)

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WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE
OKLAHOMA CITY, OK 73105
CC-FORM-5
SEND COPIES TO:
1- Employee/Claimant
1 - All Other Pares of Record
In re claim of:
Full Name of Employee (Claimant)
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
Name of Employer (Respondent)
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk
Group, Uninsured
PHYSICIAN’S REPORT ON RELEASE AND RESTRICTIONS
Employee/Counsel
Address (Number & Street)
City State Zip Code
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Signed this ________day of________________________________, _________.
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’ compensaon fraud, upon convicon, shall be guilty of a felony punishable by imprisonment, a
ne or both.
Revised 12-18-14
COMMISSION FILE NO.
Date of Injury
Diagnosis
Part of Body Date of Exam
RESTRICTIONS (check all that apply and describe fully under number 8 below)
II.
No Restricons Permanent Restricons Temporary Restricons
1.___Restricted liing (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 Le hand
5.___Restricted walking standing sing (describe fully) paral weight bearing (describe fully) bending twisng
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. duraon, nature of limitaon, etc.) Supplement with extra pages if needed:
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
MEDICAL & REHABILITATION
III.
A. Is connuing medical maintenance needed? NO YES If YES, describe fully, including date of next appointment. Supplement with extra
pages if needed.
B. Is vocaonal rehabilitaon 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
Employer/Counsel
Address (Number & Street)
City State Zip Code
Signature of Physician
Address (Number & Street)
City State Zip Code
Telephone Number of Physician
Print or type name of Physician
THIS SPACE FOR COMMISSION USE ONLY
YES, released to: Regular Work (date): Modied Work (date): Give Restricons (complete Secon II)
NO, claimant remains temporarily totally disabled.
I.
RELEASED
FOR
WORK?
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CC-FORM-5 PHYSICIANS REPORT ON RELEASE AND RESTRICTIONS Revised (Oklahoma)

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Completed 15 March 2022

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