FORM 5 WORKERS’ COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 SEND COPIES TO: 1- Employee/Claimant 1 - All Other Parties of Record Revised 4/06 THIS SPACE FOR COURT USE ONLY PHYSICIAN’S REPORT ON RELEASE AND RESTRICTIONS In re claim of: Full Name of Employee (Claimant) Employee’s Social Security Number Name of Employer (Respondent) FILE NO. Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Date of Injury Diagnosis Date of Exam Part of Body RELEASED I. FOR WORK? YES, released to: Regular Work (date): Modified Work (date): Give Restrictions (complete Section II) 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 1.___Restricted lifting (maximum weight in pounds) 10___ 25___ 50___ Other____ Frequency ___________ 2.___Restricted pushing/pulling of _________ lbs. 3.___Restricted reaching: above chest overhead 4.___Restricted to one-handed duty. No use of: 5.___Restricted 6.___Wear splint at: 7.___DO NOT: walking standing All Times Operate Machinery Stoop 8. away from body Right hand Left hand sitting (describe fully) Work partial weight bearing (describe fully) bending twisting Night (describe fully) Crawl Kneel Squat Drive any Vehicle Climb Bend Twist FULLY DESCRIBE RESTRICTIONS (i.e. duration, nature of limitation, etc.) Supplement with extra pages if needed: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ III. MEDICAL & REHABILITATION A. l Is continuing medical treatment needed? NO YES If YES, describe fully, including date of next appointment. 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 Signed this__________________day of__________________, ______. Address (Number & Street) City Signature of Physician State Zip Code City Employer/Counsel State Zip Code Telephone Number of Physician Address (Number & Street) City Address (Number & Street) State Zip Code Print or type name of Physician American LegalNet, Inc. www.FormsWorkflow.com