ME-OW

U.S. Department of Labor 

Office of Workers' Compensation Programs

Work Capacity Evaluation 

Psychiatric/Psychological Conditions

OMB No: 1240-0046 

Expires: 08/31/2026

OWCP No. Injured Worker's Name ( First, middle, last ) 

Please answer the questions below concerning your patient (named above) for whom the Office of Workers' Compensation 

Programs (OWCP) has accepted the following conditions as caused or aggravated by work:

1. Is the employee competent to WORK 8 hours a day? If no, your medical reasons are required to support your opinion. 

3. Is the worker competent to perform his/her usual job?

4. OWCP is committed to reemploying injured workers to the fullest extent possible. Many employers can readily 

accommodate medical restrictions including assignment of the injured worker into an alternative work location. Please note 

that if reemployment at the employing agency is not possible, the Office may pursue vocational rehabilitation for the injured 

worker. With this in mind, please describe the duties or work environment(s) which are suitable for your patient. Please be 

as detailed as possible. 

5. Please list, if any, other medical factors which need to be considered in the identification of a position for this person. 

Please explain each item.

OWCP-5a (Rev. 08-14)

2. If the employee is unable to work 8 hours a day, how many hours is he/she able to work?

a. Will the number of hours increase?

b. If yes, when will this employee be able to work eight hour work days?

c. If no, your medical reasons are required to support your opinion in a narrative report. 

If no, in a narrative report specify which aspects of 

the position are problematic. An explanation is 

required for each item.

6. Physician's Name ( Type or print ) 7. Telephone (Include Area Code) 

8. Signature 9. Date 

Yes No

Yes No
OWCP-5a PAGE 2 (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 psychiatric or psychological 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.