OWCP asks the treating physician of an injured worker whose accepted condition is musculoskeletal to complete this form, which captures the worker's specific work tolerance limits. It covers whether the worker can do the usual job, hours per day with restrictions, maximum medical improvement, strength level and limits on each activity. OWCP uses the answers to identify a position the worker can fill, and the CA-20 also points physicians to it.
The treating physician completes items 1 through 3 and signs with printed name, telephone and date in items 4 to 7. The top of the form names the injured worker, the OWCP number and the conditions OWCP has accepted; the worker and employer complete no part of it.
The top of the form names the injured worker, the OWCP file number and the conditions OWCP has accepted for your patient. Answer every question in relation to those accepted musculoskeletal conditions. If you are using a blank copy downloaded from the DOL forms page, enter the worker's name and OWCP number so the form can be matched to the case file.
Answer yes or no. A no answer needs the medical reasons in a narrative report. The form reminds physicians that many employers can readily accommodate restrictions through a modified duty assignment or an alternative work location, so a no here describes limits on the usual job, not a finding that the worker cannot work.
State whether the worker can work 8 hours a day with physical restrictions; if not, how many hours, whether you expect the hours to increase and when an 8-hour day will be reached. Each no answer needs a narrative explaining the medical reasons. Then give how long the restrictions will apply and whether maximum medical improvement has been reached.
After reviewing the Guidance for Physicians on pages 2 and 3, mark yes or no for sedentary, light, medium, heavy and very heavy work. The levels follow OWCP's definitions of force exerted occasionally, frequently and constantly; light work, for example, means up to 20 pounds occasionally or up to 10 pounds frequently, or walking and standing to a significant degree.
If the worker cannot work within a strength level, mark each activity with a limitation and give the hours the worker can perform it: sitting, walking, standing, reaching, reaching above shoulder, twisting, bending or stooping, squatting, kneeling, climbing, repetitive wrist and elbow movements, pushing, pulling, lifting, and operating a motor vehicle at work and to or from work. Give maximum pounds for lifting, pushing and pulling, plus the duration and frequency of breaks.
If other medical facts, situational factors, equipment or devices need to be considered in identifying a position for this person, explain them in a narrative report. This is the place for anything the activity grid in item 2b cannot capture, since OWCP and the employer use the form to find work within the worker's tolerances.
Type or print your name, give a telephone number with area code, then sign and date the form. Under FECA, medical evidence must come from a qualified physician; the CA-20 instructions add that nurse practitioner and physician assistant reports count only when a physician countersigns them.
These pages define the five strength levels and the frequency codes used on the OWCP-5b and OWCP-5c: not present, occasionally (up to one third of the time), frequently (one third to two thirds) and constantly (two thirds or more). They also define reaching, reaching above the shoulder, twisting, bending and stooping, operating a motor vehicle at work, repetitive elbow and wrist movements, squatting, kneeling and climbing.
Download the current version from the source each time; forms change without notice.
Work Capacity Evaluation Musculoskeletal Conditions
Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas
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Sources for this guide
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Usually when OWCP requests it for your patient, naming the accepted musculoskeletal conditions at the top of the form. You can also use it on your own: box 11 of the CA-20 Attending Physician's Report says you may complete the OWCP-5c to describe a partially disabled patient's physical limitations and the type of work they could reasonably do.
OWCP defines occasionally as up to one third of the time, a maximum of 2 hours 40 minutes in an 8-hour day; frequently as one third to two thirds of the time, up to 5 hours 20 minutes; and constantly as two thirds of the time or more. Not present means the activity or condition does not exist.
Yes. DOL posts a fillable Spanish version, Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas (OWCP-5c_ES), on its FECA forms page next to the English form. Spanish versions of the psychiatric (OWCP-5a) and cardiovascular or pulmonary (OWCP-5b) evaluations, the CA-20 and the CA-17 are posted there as well.