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U.S. Department of Labor (Federal Workers Compensation Consultants)

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ME-OW
U.S. Department of Labor
Office of Workers' Compensation Programs
Work Capacity Evaluation
Musculoskeletal Conditions
1240-0046
OWCP No.
OMB No:
Injured Worker's Name ( First, middle, last )
03-31-2021
Expires:
Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation
Programs (OWCP) has accepted the following conditions:
If no, please provide medical reasons to support your opinion in a narrative report.
1a. Is the worker capable of performing his/her
usual job without restriction?
Many employers can readily accommodate medical restrictions including modified duty assignment(s) or
assignment of the injured worker into an alternative work location.
If the claimant is unable to perform his her usual job, is the claimant able to work for 8 hours per workday with
physical restrictions? If no, please provide medical reasons to support your opinion in a narrative report.
If less that 8 hour per workday, how many can he/she work?
Do you anticipate an increase in the number of hours this person will be able to work?
If yes, when will this person achieve an 8 hour workday?
How long will the restrictions apply?
f.
Has maximum medical improvement been reached?
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 Lbs.Activity Limitation Able to Work
Sitting
Yes
Repetitive Movements:
YesWalking
Yes
Wrists
YesStanding
Elbow Yes
YesReaching
Reaching above
YesPushing
Shoulder Yes
YesPulling
YesTwisting
Yes
Lifting
YesBending/Stooping
YesSquatting
Operating Motor Vehicle
YesKneeling
at work Yes
Yes
Climbing
Breaks:
Operating a Motor Vehicle
Duration
Frequency
to/from work
Yes
Duration Frequency
If there are
OTHER
medical facts, situational factors, equipment or devices which need to be considered in the identification of a position for
this person, please explain in a narrative report.
OWCP-5c (Rev. 08-14)
b.
c.
d.
e.
g.
3.
2b. If not, please indicate whether this person has any LIMITATION in the activity listed and how many hours this person can
4. Physician's Name (Type or print)
5. Telephone Number
(Include Area Code)
6. Signature
7. Date
Yes
No
Yes No
Yes No
Yes No
If no, please provide medical reasons to support your opinion in a narrative report.
2a. Please review the Guidance for Physicians included on pages 2 and 3 of this form. Based on the parameters provided, please indicate whether this person
is capable of working within any of the following Strength Levels:
Sedentary Light Medium Heavy Very Heavy
Yes No Yes No Yes NoYes
No
Yes No
Reset
Print
OWCP has adopted the following Strength Level definitions to indicate the absence or presence and frequency
of the physical demand components requested on the OWCP-5b and OWCP-5c.
Physical Demand Definitions for the OWCP
LIMITS OF WEIGHTS LIFTED/CARRIED/PUSHED/PULLED
Rating Occasionally Frequently Constantly
Sedentary * - 10 * N/A
Light * - 20 * - 10 *
Medium 20 - 50 10 - 25 * - 10
Heavy 50 - 100 25 - 50 10 - 20
Very Heavy 100 + 50 + 20 +
* = negligible weight; N/A = Not Applicable
The range excludes the lower number and includes the higher number, i.e., the range 10 - 25 excludes 10
(begins at 10 +) and includes 25.
Very Heavy Work
Very Heavy work involves exerting in excess of 100 pounds of force occasionally, or in excess of 50 pounds
of force frequently or in excess of 20 pounds of force constantly to move objects, Physical demand
requirements are in excess of those for Heavy Work.
Heavy Work
Heavy Work involves exerting 50 to 100 pounds of force occasionally, or 25 to 50 pounds of force frequently,
or 10 to 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those
for Medium Work.
Medium Work
Medium Work involves exerting 20 to 50 pounds of force occasionally or 10 to 25 pounds of force frequently
or an amount greater than negligible and up to 10 pounds constantly to move objects. Physical demand
requirements are in excess of these for Light Work.
Light Work
Light Work involves exerting up to 20 pounds of force occasionally or up to 10 pounds of force frequently, or a
negligible amount of force constantly to move objects. Physical demand requirements are in excess of those
for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job/occupation is rated
Light Work when it requires: (1) walking or standing to a significant degree; (2) sitting most of the time while
pushing or pulling arm or leg controls; or (3) working at a production rate pace while constantly pushing or
pulling materials even though the weight of the materials is negligible. (The constant stress and strain of
maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a
worker even though the amount of force exerted is negligible.)
Sedentary Work
Sedentary Work involves exerting up to 10 pounds of force occasionally or a negligible amount of force
frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work
involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs may be
defined as Sedentary when walking and standing are required only occasionally and all other Sedentary
criteria are met.
1. STRENGTH LEVEL
OWCP-5c PAGE 2 (Rev. 08-14)
Physical Demand Definitions for the OWCP (continued)
Code Frequency
Definition
Max # hrs./8-hr. day
N Not Present Activity/condition does not exist. 0
O Occasionally Activity/condition exists up to 1/3 of the time. 2 hrs. 40 min.
F Frequently
Activity/condition exists from 1/3 to 2/3 of the time.
5 hrs. 20 min.
C Constantly
Activity/condition exists 2/3 or more of the time.
8
6. OPERATING A MOTOR VEHICLE AT WORK
Driving any vehicle during the performance of one's duties.
5. BENDING/STOOPING
Bending body downward and forward by bending spine at the waist requiring full use of the lower extremities
and back muscles.
4. TWISTING
Turning, twisting, contorting, or flexing the torso in any direction towards the right or left.
3. REACHING ABOVE THE SHOULDER
Forward flexion and/or abduction of the hand(s) and arm(s); generally at greater than 90◦ from the shoulder.
2. REACHING
Forward flexion and/or abduction of the hand(s) and arm(s); generally, within a 0◦ - 90◦ range of motion from
the shoulder; or extension within a 0◦ - 50 ◦ range of motion from the shoulder.
PRESENCE AND/OR FREQUENCY OF OTHER PHYSICAL DEMANDS
The following codes and definitions indicate the absence or presence and frequency of other Physical
Demand components requested on the OWCP-5b and OWCP-5c.
7. REPETITIVE MOVEMENTS OF ELBOWS (HANDLING)
Seizing, holding, grasping, turning, or otherwise working with hand or hands using the whole arm.
8. REPETITIVE MOVEMENTS OF WRISTS (FINGERING)
Picking, pinching, or otherwise working primarily with fingers and wrists rather than the whole arm as in
handling.
9. SQUATTING (CROUCHING)
Bending body downward and forward by bending legs and spine.
10. KNEELING
Bending legs at knees to come to rest on knee or knees.
11. CLIMBING
Ascending or descending ladders, stair, scaffolding, ramps, poles, and the like, using feet and legs or hands
and arms. Body agility is emphasized.
OWCP-5c PAGE 3 (Rev. 08-14)
OWCP-5c PAGE 4 (Rev. 08-14)
Privacy 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 musculoskeletal 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
Requests for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP in the form
of communication assistance, accommodation(s) and/or modification(s) 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 accommodate your disability. Please contact our office or your OWCP claims
examiner to ask about this assistance.
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Completed 5 May 2021

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