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 (LAST 4 DIGITS ONLY) XXX-XX-________________________ Name of Employer (Respondent) FORM 5 COURT OF EXISTING CLAIMS 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 PHYSICIAN'S REPORT ON RELEASE AND RESTRICTIONS C. 11/02/2015 THIS SPACE FOR COURT USE ONLY WCC 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. 1. Is Additional active medical treatment recommended? NO 2. Is continuing medical maintenance recommended? NO YES YES If YES, describe fully, including date of next appointment. Supplement with If YES, describe fully, including recommended medications, supportive extra pages if needed. ____________________________________________________________________________________________________ devices, etc. Supplement with extra pages if needed. ___________________________________________________________________________ B. 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 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 American LegalNet, Inc. www.FormsWorkFlow.com