Free Form 5.pub - Oklahoma

SEND COPIES TO: 1- Employee/Claimant 1 - All Other Parties of Record In re claim of:
Full Name of Employee (Claimant) Employee's Social Security Number Name of Employer (Respondent)

FORM 5

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
PHYSICIAN'S REPORT ON RELEASE AND RESTRICTIONS

Revised 4/06
THIS SPACE FOR COURT USE ONLY

FILE NO. Date of Injury Part of Body Diagnosis Date of Exam

Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured

RELEASED

YES, released to:

Regular Work (date):

Modified Work (date):

Give Restrictions (complete Section II)

I.

FOR WORK?

NO, claimant remains temporarily totally disabled.

II. RESTRICTIONS (check all that apply and describe fully under number 8 below)
No Restrictions Permanent Restrictions Temporary Restrictions Frequency ___________ 1.___Restricted lifting (maximum weight in pounds) 10___ 25___ 50___ Other____ 2.___Restricted pushing/pulling of _________ lbs. 3.___Restricted reaching: 5.___Restricted 6.___Wear splint at: 7.___DO NOT: 8. walking All Times Operate Machinery Stoop Twist above chest standing Work overhead Right hand sitting (describe fully) Night (describe fully) Crawl Kneel Squat Drive any Vehicle Climb Bend away from body Left hand partial weight bearing (describe fully) bending twisting 4.___Restricted to one-handed duty. No use of:

FULLY DESCRIBE RESTRICTIONS (i.e. duration, nature of limitation, etc.) Supplement with extra pages if needed: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

III. MEDICAL & REHABILITATION
A. B. Is continuing medical treatment needed? NO with extra pages if needed. Is vocational rehabilitation indicated? (i.e. As a result of the injury, is the employee unable to perform the same occupational duties the employee was performing before the injury?) NO YES YES If YES, describe fully, including date of next appointment. Supplement

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee/Counsel Address (Number & Street) City State Zip Code Address (Number & Street)

Signed this__________________day of__________________, ______.
Signature of Physician

Employer/Counsel Address (Number & Street) City State Zip Code

City Telephone Number of Physician Print or type name of Physician

State

Zip Code