Medium

Available on

Apple Android Windows

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
  • oxy
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

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.'}}

  • {{data.title}}

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!

Related Human Resources & Time Management Apps... and they're all free for GoCanvas subscribers!

App Name

Chemical Hazard Communication Program...

The Chemical Hazard Communication Program Checklist will help you determine whether you have met all of the safety and hea...

App Name

Interview Preparation: How do I prepa...

Please take the time to review and think of your own personal responses using the Interview Preparation: How do I prepare ...

App Name

HIV Confidentiality and Security Prin...

The purpose the HIV Confidentiality and Security Principles mobile app is to define the health information confidentiality...

App Name

Accident and Illness Report - Deluxe

This Accident and Illness Report from Deluxe® Mobile App allows for the collection of data pertaining to any work injury o...

App Name

USDA: Service Branch Director Positio...

The USDA: Service Branch Director Position Checklist mobile app checklist should be considered the minimum required for th...

App Name

Interviewing Preparation Tips and Sug...

After an interview, once an employer thanks you for coming in and interviewing, the formal interview has concluded; howeve...

App Name

Confidentiality Clause

The Confidentiality Clause mobile app provides an example of a confidentiality clause which is only as a convenience, t...

App Name

Human Resources-Consent to Drug Test

This Human Resources-Consent to Drug Test Mobile App facilitates a simple consent form for drug testing. This app is ideal...

More Information