Ohio BWC's Disability Evaluator Panel examiners use this form when a claim involves cognitive or psychological conditions. The examiner circles a restriction level for each work-related ability, from Class 1 (no restriction) to Class 5 (restriction levels preclude useful functioning), based on the clinical evaluation and testing. BWC reads it with the examination report to judge how many hours and days the injured worker can work.
The BWC Disability Evaluator Panel physician or psychologist completes and signs the whole form. The injured worker does not complete any part.
Download the current version from the source each time; forms change without notice.
Disability Evaluator Panel (DEP) Physician's Report of Work Ability Cognitive/Psychological Conditions
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It rates self-care and travel, dealing with the public, communicating, accepting supervision and managing conflict, handling complex or simple tasks and decisions, concentration, memory for locations and procedures, awareness of hazards, keeping a schedule, and performing under stress and work pressure. Each item is circled at one of five restriction levels.
The form is signed by the Disability Evaluator Panel examiner who evaluated the injured worker, a physician or psychologist on BWC's panel. The signature line is marked required and sits under a certification that false statements to obtain BWC payment can lead to felony prosecution.