The purpose of this form is to obtain the claimant's specific work tolerance limitation where the accepted condition is psychiatric or psychological in nature.
Hours: Is the employee competent to WORK 8 hours a day? If no, your medical reasons are required to support your opinion.
Usual job: Is the worker competent to perform his/her usual job?
Duties: please describe the duties or work environment(s) which are suitable for your patient. Please be as detailed as possible.
Vocational rehabilitation: if reemployment at the employing agency is not possible, the Office may pursue vocational rehabilitation for the injured worker.
| Question | Answer |
|---|---|
| Form Name | Form OWCP-5a |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 23 |
| Avg. time to fill out | 4 min |
| Edition | 08-14 |
| Issuing agency | Department of Labor, Office of Workers' Compensation Programs |
| Other names | OWCP-5a, OWCP5a, OWCP 5a, OWCP-5A, OWCP 5A form, Form OWCP-5a, ME-OW, Work Capacity Evaluation Psychiatric/Psychological Conditions |
| Official source | Form OWCP-5a (Rev 08-14), Office of Workers' Compensation Programs |
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