ME-OW

U.S. Department of Labor 

Office of Workers' Compensation Programs

Work Capacity Evaluation 

Musculoskeletal Conditions

Injured Worker's Name ( First, middle, last ) OWCP No. OMB No: 1240-0046

 Expires: 08/31/2026

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? 

f. How long will the restrictions apply?

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 Activity Limitation Able to Work Lbs.

Sitting Yes Repetitive Movements:

Walking Yes Wrists Yes

Standing Yes Elbow Yes

Reaching Yes

Reaching above Pushing Yes

Shoulder Yes Pulling Yes

Twisting Yes Lifting Yes

Bending/Stooping Yes Squatting Yes

Operating Motor Vehicle at work Kneeling YesYes Climbing Yes

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 Yes No Light Yes No Medium Yes No Heavy Yes No Very Heavy Yes No
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.