source: FOIAVistA/tag/r/ASISTS-OOPS/OOPSPC20.m@ 1154

OOPSPC20 ;HIRMFO/YH-FEDERAL EMPLOYEE'S NOTICE OF TRAUMATIC INJURY - SUPERVISOR'S REPORT ;2/19/98
 ;;2.0;ASISTS;;Jun 03, 2002
EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
 W !,$CHAR(27),"E",$CHAR(27),"&l1E",$CHAR(27),"*c5952x7920Y",$CHAR(27),"%0B",$CHAR(27),"&s1#C"
 W !,"IN;SP1;IP;PW.3;SC0,22,0,29,1;"
 W !,"DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;"
 W !,"PU.5,28.8;LBOfficial Supervisor's Report: Please complete information requested below:#;"
 W !,"PU.4,28.2;FT10,10;RA21,28.6;EA21,28.6;PU.5,28.3;LBSupervisor's Report#;"
 W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU.5,27.9;LB17. Agency name and address of reporting office (Include city, state, and ZIP code)#;"
 W !,"PU17,28.2;PD17,27.3;PU17.1,27.9;LBOWCP Agency Code#;"
 W !,"PU15.7,26.4;PD15.7,27.3;PU15.8,27;LBOSHA Site Code#;PU14.5,26.1;LBZIP Code#;"
 W !,"PU.5,27.3;PD21,27.3;PU.5,26.4;PD21,26.4;"
 W !,"PU.5,26.1;LB18. Employee's duty station (Street address and ZIP code)#;"
 W !,"PU.5,25.6;PD21,25.6;"
 W !,"PU.5,25.3;LB19. Employee's retirement coverage#;"
 W !,"PU7.2,25.3;EA7.4,25.1;PU7.8,25.1;LBCSRS#"
 W !,"PU9.2,25.3;EA9.4,25.1;PU9.8,25.1;LBFERS#"
 W !,"PU11.2,25.3;EA11.4,25.1;PU11.8,25.1;LBOther, (Identify)#"
 W !,"PU.5,24.7;PD21,24.7;"
 W !,"PU.5,24.4;LB20. Regular#;PU1,24;LBwork#;PU1,23.6;LBhours#;PU2.2,23.6;LBFrom#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU3.4,23.6;LB:#;"
 W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU4.1,24.2;EA4.3,24.4;PU4.5,24.2;LBa.m.#;PU4.1,23.7;EA4.3,23.9;PU4.5,23.7;LBp.m.#;PU5.8,23.6;LBTo#;"
 W !,"SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.8,23.6;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU7.4,24.2;EA7.6,24.4;PU7.8,24.2;LBa.m.#;PU7.4,23.7;EA7.6,23.9;PU7.8,23.7;LBp.m.#;"
 W !,"PU8.9,24.7;PD8.9,23.4;PU9,24.4;LB21. Regular#;PU9.6,24;LBwork#;PU9.6,23.6;LBschedule#;"
 W !,"PU11,23.6;EA11.2,23.8;PU11.4,23.6;LBSun.#;PU12.3,23.6;EA12.5,23.8;PU12.7,23.6;LBMon.#;"
 W !,"PU13.6,23.6;EA13.8,23.8;PU14,23.6;LBTues.#;PU14.9,23.6;EA15.1,23.8;PU15.3,23.6;LBWed.#;"
 W !,"PU16.2,23.6;EA16.4,23.8;PU16.6,23.6;LBThurs.#;PU17.7,23.6;EA17.9,23.8;PU18.1,23.6;LBFri.#;"
 W !,"PU18.8,23.6;EA19,23.8;PU19.2,23.6;LBSat.#;"
 W !,"PU.5,23.4;PD21,23.4;PU.5,23.1;LB22. Date#;PU2.5,23.1;LBMo.#;PU3.5,23.1;LBDay#;PU4.5,23.1;LBYr.#;"
 W !,"PU5.6,23.4;PD5.6,22.4;PU5.7,23.1;LB23. Date#;PU8,23.1;LBMo.#;PU9,23.1;LBDay#;PU10,23.1;LBYr.#;"
 W !,"PU11,23.4;PD11,22.4;PU11.1,23.1;LB24. Date#;PU13.2,23.1;LBMo.#;PU14.2,23.1;LBDay#;PU15.2,23.1;LBYr.#;"
 W !,"PU1,22.8;LBof#;PU6.2,22.8;LBnotice#;PU11.6,22.8;LBstopped#;"
 W !,"PU1,22.5;LBinjury#;PU2.2,22.5;PD5.2,22.5;PU2.2,22.5;PD2.2,22.7;PU3.2,22.5;PD3.2,22.7;PU4.2,22.5;PD4.2,22.7;PU5.2,22.5;PD5.2,22.7;"
 W !,"PU6.2,22.5;LBreceived#;PU7.7,22.5;PD10.5,22.5;PU7.7,22.5;PD7.7,22.7;PU8.7,22.5;PD8.7,22.7;"
 W !,"PU9.7,22.5;PD9.7,22.7;PU10.5,22.5;PD10.5,22.7;"
 W !,"PU11.6,22.5;LBwork#;PU12.9,22.5;PD15.7,22.5;PU12.9,22.5;PD12.9,22.7;PU13.9,22.5;PD13.9,22.7;"
 W !,"PU14.8,22.5;PD14.8,22.7;PU15.7,22.5;PD15.7,22.7;"
 W !,"PU16,22.5;LBTime#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU17.2,22.5;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU17.8,23;EA18,23.2;PU18.2,23;LBa.m.#;PU17.8,22.5;EA18,22.7;PU18.2,22.5;LBp.m.#;"
 W !,"PU.5,22.4;PD21,22.4;"
 W !,"PU.5,22.1;LB25.Date#;PU2.5,22.1;LBMo.#;PU3.5,22.1;LBDay#;PU4.5,22.1;LBYr.#;PU5.5,22.4;PD5.5,21.3;PU5.6,22.1;LB26.Date#;"
 W !,"PU6.1,21.8;LB45 day#;"
 W !,"PU8.4,22.1;LBMo.#;PU9.3,22.1;LBDay#;PU10.3,22.1;LBYr.#;PU11.3,22.4;PD11.3,21.3;PU11.4,22.1;LB27.Date#;"
 W !,"PU13.4,22.1;LBMo.#;PU14.4,22.1;LBDay#;PU15.4,22.1;LBYr.#;"
 W !,"PU1,21.8;LBpay#;PU1,21.5;LBstopped#;PU2.2,21.5;PD5.2,21.5;PU2.2,21.5;PD2.2,21.7;PU3.2,21.5;PD3.2,21.7;"
 W !,"PU4.2,21.5;PD4.2,21.7;"
 W !,"PU5.2,21.5;PD5.2,21.7;"
 W !,"PU6.1,21.5;LBperiod began#;PU8.2,21.5;PD11,21.5;PU8.2,21.5;PD8.2,21.7;PU9.1,21.5;PD9.1,21.7;"
 W !,"PU10.1,21.5;PD10.1,21.7;PU11,21.5;PD11,21.7;"
 W !,"PU11.9,21.8;LBreturned#;PU11.9,21.5;LBto work#;PU13.2,21.5;PD16,21.5;PU13.2,21.5;PD13.2,21.7;"
 W !,"PU14.2,21.5;PD14.2,21.7;PU15.2,21.5;PD15.2,21.7;"
 W !,"PU16,21.5;PD16,21.7;PU16.3,21.5;LBTime#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU17.5,21.5;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU18.2,21.9;EA18.4,22.1;PU18.6,21.9;LBa.m.#;PU18.2,21.5;EA18.4,21.7;PU18.6,21.5;LBp.m.#;"
 W !,"PU.5,21.3;PD21,21.3;"
 W !,"PU.5,21;LB28. Was employee injured in performance of duty?#"
 W !,"PU7.6,21;EA7.8,21.2;PU8,21;LBYes#;PU9,21;EA9.2,21.2;PU9.4,21;LBNo#;PU10,21;LB(If ""No,"" explain)#;"
 W !,"PU.5,19.8;PD21,19.8;PU.5,19.5;LB29. Was injury caused by employee's willful misconduct, intoxication,#;"
 W !,"LB or intent to injure self or another?#;"
 W !,"PU15,19.5;EA15.2,19.7;PU15.4,19.5;LBYes#;PU16.2,19.5;LB(If ""Yes,"" explain)#;"
 W !,"PU19.2,19.5;EA19.4,19.7;PU19.6,19.5;LBNo#;"
 W !,"PU.5,18.4;PD21,18.4;PU.5,18.1;LB30. Was injury caused#;PU4.2,18.4;PD4.2,15.8;PU4.2,17.6;PD21,17.6;PU4.2,16.7;PD21,16.7;"
 W !,"PU4.3,18.1;LB31. Name and address of third party (Include city, state, and ZIP code)#;"
 W !,"PU1,17.7;LBby third party?#;PU1,17.3;EA1.2,17.5;PU1.4,17.3;LBYes#;PU2.7,17.3;EA2.9,17.5;PU3.1,17.3;LBNo#;"
 W !,"PU2.7,16.9;LB(If ""No,""#;PU2.7,16.5;LBgo to#;PU2.7,16.1;LBitem 32.)#;"
 W !,"PU.5,15.8;PD21,15.8;PU.5,15.5;LB32. Name and address of physician first providing medical care#;"
 W !,"LB (Include city, state, ZIP code)#;"
 W !,"PU14.5,15.8;PD14.5,13.1;PU14.6,15.5;LB33. First date#;PU17.1,15.4;LBMo.#;PU18.1,15.4;LBDay#;PU19.1,15.4;LBYr.#;"
 W !,"PU15.1,15.2;LBmedical care#;PU15.1,14.9;LBreceived#;PU14.5,14.6;PD21,14.6;"
 W !,"PU16.8,14.8;PD19.6,14.8;PU16.8,14.8;PD16.8,15;PU17.8,14.8;PD17.8,15;PU18.7,14.8;PD18.7,15;PU19.6,14.8;PD19.6,15;"
 W !,"PU14.6,14.3;LB34. Do medical#;PU15.1,14;LBreports show#;PU15.1,13.7;LBemployee is#;PU15.1,13.4;LBdisabled for work?#;"
 W !,"PU17.4,14.1;EA17.6,14.3;PU17.8,14.1;LBYes#;PU18.8,14.1;EA19,14.3;PU19.2,14.1;LBNo#;"
 W !,"PU.5,14.8;PD14.5,14.8;PU.5,13.9;PD14.5,13.9;PU.5,13.1;PD21,13.1;PU14.5,15.8;PU14.5,13.1;"
 W !,"PU.5,12.8;LB35. Does your knowledge of the facts about this injury agree with statements#;"
 W !,"LB of the employee and/or witness?#;"
 W !,"PU15.8,12.7;EA16,12.9;PU16.2,12.7;LBYes#;PU17.1,12.7;EA17.3,12.9;PU17.5,12.7;LBNo (If ""No,"" explain)#;"
 W !,"PU.5,11.3;PD21,11.3;PU.5,11;LB36. If the employing agency controverts continuation of pay, state the reason in detail.#;"
 W !,"PU14.3,9.7;PD14.3,11.3;PU14.4,11;LB37. Pay rate#;PU15,10.7;LBwhen employee#;PU15,10.4;LBstopped work#;"
 W !,"PU15,9.9;LB$#;PU17.9,9.9;LBPer#;"
 W !,"PU.5,9.3;RA21,9.7;EA21,9.7;"
 W !,"PU.5,9.2;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.4;LBSignature of Supervisor and Filing instructions#;"
 W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9;LB38. A supervisor who knowingly certifies to any false statement,#;"
 W !,"LB misrepresentation, concealment of fact, etc., in respect of this claim#;"
 W !,"PU1.1,8.6;LBmay also be subject to appropriate felony criminal prosecution.#;"
 W !,"PU1.1,7.9;LBI certify that the information given above and that furnished by the employee on the reverse#;"
 W !,"LB of this form is true to the best of my#;"
 W !,"PU1.1,7.6;LBknowledge with the following exception:#;"
 W !,"PU.5,6.8;PD21,6.8;PU.5,6.5;LBName of supervisor (Type or print)#;"
 W !,"PU.5,6.1;PD21,6.1;PU.5,5.8;LB Signature of supervisor#;PU12.9,5.8;LBDate#;"
 W !,"PU.5,5.3;PD21,5.3;PU.5,5;LBSupervisor's Title#;PU12.9,5;LBOffice phone#;"
 W !,"PU.5,4.6;PD21,4.6;PU.5,4.3;LB39. Filing instructions#;"
 W !,"PU4.7,3.9;EA4.9,4.1;PU5.1,4.3;LBNo lost time and no medical expense: Place this form in employee's medical folder (SF-66-D)#;"
 W !,"PU4.7,4.3;EA4.9,4.5;PU5.1,3.9;LBNo lost time, medical expense incurred or expected: forward this form to OWCP#;"
 W !,"PU4.7,3.5;EA4.9,3.7;PU5.1,3.5;LBLost time covered by leave, LWOP, or COP: forward this form to OWCP#;"
 W !,"PU4.7,3.1;EA4.9,3.3;PU5.1,3.1;LBFirst Aid injury#;"
 W !,"PU.5,3;PD21,3;PU17.5,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBForm CA-1#;PU17.5,2.1;LBRev. Apr. 1999#;"
 D:IEN>0 ^OOPSPC21
 W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q