Submit the completed form to the U.S. Department of Labor Office of Workers' Compensation Programs. You can send it via mail to 200 Constitution Ave NW, Washington, DC 20210, fax it to (202) 513-6814, or use the online submission form available on the DOL website. Ensure all required fields are filled out, and supporting narrative reports are attached. Review the completed form and keep a copy for your records. It is essential to submit the form promptly to avoid delays in the benefits process.

The form is valid until 08/31/2026.

The Work Capacity Evaluation for Musculoskeletal Conditions form is used by physicians to assess the work capabilities of injured workers. This evaluation helps determine whether the worker can return to their usual job or requires any modifications based on their medical condition. The form provides detailed information about the worker's physical capabilities and any necessary work restrictions. The form is crucial for employers, workers' compensation program administrators, and HR personnel, ensuring that injured workers receive appropriate accommodations and support. By providing a comprehensive evaluation of the worker's physical limitations, it helps identify any modifications needed for a safe return to work. The form also assists in determining the extent of the injury and any long-term effects on the worker's ability to perform job-related tasks. Completing this form accurately is essential for all stakeholders involved. Physicians must provide detailed and honest assessments, while employers and workers' compensation program administrators must review the information carefully to implement any necessary accommodations. Timely submission of the form ensures that injured workers receive the support and benefits they are entitled to under the workers' compensation program.

• 1. Injured Worker's Name: Enter the full name of the injured worker.
• 2. OWCP No.: Provide the OWCP number assigned to the case.
• 3. OMB No.: Enter the OMB number as indicated.
• 4. Section 1a: Indicate if the worker can perform their usual job without restrictions and provide medical reasons if not.
• 5. Section 1b: Specify if the worker can work for 8 hours per day with restrictions and provide medical reasons if not.
• 6. Section 1c: If less than 8 hours per day, state the number of hours the worker can work.
• 7. Section 1d: Indicate if an increase in work hours is anticipated and when the worker will achieve an 8-hour workday.
• 8. Section 1e: Provide medical reasons if the worker is not expected to achieve an 8-hour workday.
• 9. Section 1f: Indicate the duration of the restrictions.
• 10. Section 1g: State if maximum medical improvement has been reached.
• 11. Section 2a: Indicate if the worker is capable of working within various strength levels (Sedentary, Light, Medium, Heavy, Very Heavy).
• 12. Section 2b: Specify any limitations in activities such as sitting, walking, standing, reaching, etc., and the number of hours the worker can perform each activity.
• 13. Section 3: Provide any other medical facts, situational factors, or required equipment or devices in a narrative report.
• 14. Physician's Contact Information: Include physician's name, telephone number, signature, and date.

Failure to submit this form may result in delays or denial of workers' compensation benefits. It is crucial to complete and submit the form to ensure proper evaluation and support for the injured worker.

• Delay in Benefits: Workers' compensation benefits may be delayed or denied without timely submission.
• Inadequate Support: Injured workers may not receive the necessary accommodations or support for their condition.

• 1. Post-Injury Evaluation: Assess the worker's ability to perform their job after an injury.
• 2. Determining Work Restrictions: Identify any necessary work modifications or restrictions based on the worker's condition.