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Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions) Mobile App

The Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions) mobile app allows employees and employers to replace the paper version of the U.S. Department of Labor Office of Workers' Compensation Programs form OWCP-5b with a mobile app. This app creates a PDF that can easily be stored or emailed. You can save partially completed apps.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions) Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    U.

  • Ico textbox

    Injured Worker's Name ( First, middle, last )

  • Ico textbox

    OWCP No.

  • Ico textbox

    OMB No:

  • Ico date

    Expires:

  • Ico multiline

    Please answer the questions below concerning your patient (named above) for whom the Office of Wo...

  • Ico dropdown

    a.

  • Ico dropdown

    If no, is prevention (of possible future injury) the only reason for work limitations?

  • Ico multiline

    If prevention is not the only reason, please explain your medical reason for limitations:

  • Ico statictext

    Many employers can readily accommodate medical restrictions including assignment of the injured w...

  • Ico dropdown

    b.

  • Ico decimal

    c.

  • Ico dropdown

    d.

  • Ico textbox

    If yes, when will this person achieve an 8 hour workday?

  • Ico multiline

    If no, please provide medical reasons to support your opinion:

  • Ico statictext

    2. Has the work injury/condition caused ANATOMICAL and/or FUNCTIONAL changes in the cardiovascula...

  • Ico dropdown

    a.

  • Ico dropdown

    b.

  • Ico dropdown

    c.

  • Ico dropdown

    d.

  • Ico multiline

    Is the person taking MEDICATIONS that impact the ability to work?

  • Ico multiline

    Are there OTHER medical factors, situational considerations (e.

  • Ico textbox

    6. Physician's Name

  • Ico textbox

    7. Telephone Number (Include Area Code)

  • Ico signature

    8. Signature

  • Ico date

    9. Date

  • Ico dropdown

    Please indicate whether this person has any LIMITATION in the activity listed and how many hours...

  • Ico textbox

    Limitation

  • ...and More!

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