owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Condi

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U.S. Department of Labor

Work Capacity Evaluation
Cardiovascular/Pulmonary Conditions

Office of Workers' Compensation Programs

OMB No: 1240-0046

OWCP No.

Injured Worker's Name ( First, middle, last )

Expires: 03-31-2021
Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation Programs (OWCP) has
accepted the following conditions:

✲❁❄❉❏

1a. Is this employee capable of performing his/her usual job without restriction?
No If no, is prevention (of possible future injury)
Yes
the only reason for work limitations?
No If prevention is not the only reason, please explain your medical reason to support
Yes
your opinion in a medical report.

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 physical 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?
If yes, when will this person achieve an 8 hour workday?
If no, please provide medical reasons to support your opinion in a medical report:

Yes

No

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
No
b. Airborne particles
d. Electromagnetic radiation
Yes
No

Yes
Yes

No
No

3a. 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
Yes
No
Yes
No
Medium

Yes

No

Heavy

Yes

No

Very Heavy

Yes

No

3b. If not, 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
# of Hours
Activity
Limitation
Able to Work
Activity
Limitation
Able to Work
Lbs.
Sitting
Walking
Standing
Reaching
Reaching above

Yes
Yes
Yes
Yes

Shoulder
Twisting
Bending/Stooping
Operating Motor Vehicle at work

Yes
Yes
Yes

Duration
Operating a Motor Vehicle
to/from work

Yes
Frequency

Repetitive Movements:
Yes
Yes

Wrists
Elbow
Pushing
Pulling
Lifting
Squatting
Kneeling
Climbing
Breaks: Duration

Yes
Yes
Yes
Yes
Yes
Yes
Frequency

Yes

4. Is the person taking MEDICATIONS that impact the ability to work? Please explain.

5. If there are 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, please explain in a narrative report.

6. Physician's Name ( Type or print )

7. Telephone Number (Include Area Code)

8. Signature

9. Date
OWCP-5b (Rev. 08-14)

Physical Demand Definitions for the OWCP
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.
1. STRENGTH LEVEL
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.
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.)
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.
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.
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.

LIMITS OF WEIGHTS LIFTED/CARRIED/PUSHED/PULLED
Rating

Occasionally

Sedentary
* - 10
Light
* - 20
Medium
20 - 50
Heavy
50 - 100
Very Heavy
100 +
* = negligible weight; N/A = Not Applicable

Frequently

Constantly

*
* - 10
10 - 25
25 - 50
50 +

N/A
*
* - 10
10 - 20
20 +

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.

OWCP-5b PAGE 2 (Rev. 08-14)

Physical Demand Definitions for the OWCP (continued)
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.
Code

Frequency

Definition

Max # hrs./8-hr. day

N
O
F
C

Not Present
Occasionally
Frequently
Constantly

Activity/condition does not exist.
Activity/condition exists up to 1/3 of the time.
Activity/condition exists from 1/3 to 2/3 of the time.
Activity/condition exists 2/3 or more of the time.

0
2 hrs. 40 min.
5 hrs. 20 min.
8

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.
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.
4. TWISTING
Turning, twisting, contorting, or flexing the torso in any direction towards the right or left.
5. BENDING/STOOPING
Bending body downward and forward by bending spine at the waist requiring full use of the lower extremities
and back muscles.
6. OPERATING A MOTOR VEHICLE AT WORK
Driving any vehicle during the performance of one's duties.
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-5b PAGE 3 (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 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
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.

OWCP-5b PAGE 4 (Rev. 08-14)