OWCP uses this four-page form to learn what an injured worker with an accepted cardiovascular or pulmonary condition can do at work. The treating physician says whether the usual job is possible and for how many hours, whether exposure to temperature extremes, airborne particles, gas, fumes or electromagnetic radiation must be avoided, the strength level, and limits on specific activities.
The treating physician completes and signs it, using the physical demand definitions OWCP provides on pages 2 and 3.
Download the current version from the source each time; forms change without notice.
Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
Evaluación de la capacidad de trabajo Condiciones cardiovasculares / pulmonares
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. DOL posts a Spanish version, Evaluación de la capacidad de trabajo, condiciones cardiovasculares / pulmonares, next to the English form on its FECA forms page, with the same questions and physical demand definitions.
Sedentary, light, medium, heavy and very heavy, defined on page 2. Medium work, for instance, means 20 to 50 pounds occasionally or 10 to 25 pounds frequently. If the worker fits none, item 3b records limits and hours for each activity instead.
OWCP defines occasionally as up to one-third of the time, frequently as one-third to two-thirds, and constantly as two-thirds or more. In an 8-hour day that is up to 2 hours 40 minutes for occasional and up to 5 hours 20 minutes for frequent activity.