source: FOIAVistA/tag/r/ASISTS-OOPS/OOPSPC40.m@ 1185

OOPSPC40 ;HIRMFO/YH-CA-2 PAGE 1 ;2/20/98
 ;;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;"
 W !,"SD1,277,2,1,4,12,5,0,6,0,7,16901;PU.4,28.7;LBNotice of Occupational Disease@;"
 W !,"PU.4,28.2;LBand Claim for Compensation@;"
 W !,"SD1,277,2,1,4,12,5,0,6,1,7,23;PU10.5,28.7;LBU.S. Department of Labor@;"
 W !,"SD1,277,2,1,4,10,5,0,6,0,7,16901;PU10.5,28.2;LBEmployment Standards Administration@;"
 W !,"PU10.5,27.9;LBOffice of Workers' Compensation Programs@;"
 W !,"PU.4,27.7;PD21,27.7;"
 W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,27.3;LBEmployee: Please complete all boxes 1 - 18 below. Do not complete shaded areas.@;"
 W !,"PU.4,26.9;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.@;"
 W !,"PU.4,26.7;PD21,26.7;PU.4,26.3;FT10,10;RA21,26.7;PU.4,26.4;LBEmployee Data@;PU.4,26.3;PD21,26.3;"
 W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.4,26;LB1. Name of employee (Last, First, Middle)@;"
 W !,"PU15.7,26.3;PD15.7,25.4;PU15.8,26;LB2. Social Security Number@;PU.4,25.4;PD21,25.4;"
 W !,"PU.4,25.1;LB3. Date of birth@;PU3,25.1;LBMo.@;PU3.9,25.1;LBDay@;PU4.9,25.1;LBYr.@;"
 W !,"PU6.3,24.6;PD6.3,25.4;PU6.4,25.1;LB4. Sex@;PU8,25.4;PD8,24.6;PU8.1,25.1;LB5. Home telephone@;"
 W !,"PU12.4,25.4;PD12.4,24.6;PU12.5,25.1;LB6. Grade as of date@;"
 W !,"PU2.9,24.7;PD5.4,24.7;PU2.9,24.7;PD2.9,24.9;PU3.7,24.7;PD3.7,24.9;PU4.7,24.7;PD4.7,24.9;PU5.4,24.7;PD5.4,24.9;"
 W !,"PU13,24.7;LBof last exposure@;PU15.6,24.7;LBLevel@;PU17.9,24.7;LBStep@;"
 W !,"PU.4,24.6;PD21,24.6;PU.4,24.3;LB7. Employee's home mailing address (Include city, state, and zip code)@;"
 W !,"PU15.9,24.3;LB8. Dependents@;PU16.2,23.8;EA16.4,24;PU16.6,23.8;LBWife, Husband@;"
 W !,"PU16.2,23.4,EA16.4,23.6;PU16.6,23.4;LBChildren under 18 years@;"
 W !,"PU16.2,23;EA16.4,23.2;PU16.6,23;LBOther@;"
 W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU15.8,21.7;LBa. Occupation code@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU.4,22.5;PD21,22.5;PU15.8,24.6;PD15.8,22.5;"
 W !,"PU.4,22;PD21,22;PU.4,22.1;SD1,277,2,1,4,9,5,0,6,1,7,23;LBClaim Information@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU.4,22;RA21,22.5;PU.4,21.7;LB9. Employee's occupation@;PU.4,20.7;PD21,20.7;"
 W !,"PU.4,20.4;LB10. Location (address) where you worked when disease or illness occurred (Include city, state, and zip code)@;"
 W !,"PU15.8,20.4;LB11. Date you first became@;PU16.3,20.1;LBaware of disease@;"
 W !,"PU16.3,19.7;LBor illness@;PU16.3,19.3;LBMo.@;PU17.3,19.3;LBDay@;PU18.3,19.3;LBYr.@;"
 W !,"PU16.3,18.7;PD18.7,18.7;PU16.3,18.7;PD16.3,18.9;PU17.1,18.7;PD17.1,18.9;PU18,18.7;PD18,18.9;PU18.7,18.7;PD18.7,18.9;"
 W !,"PU.4,18.6;PD15.7,18.6;EA21,22;PU15.7,20.7;RA21,22;"
 W !,"PU.4,18.3;LB12. Date you first realized@;PU.9,18;LBthe disease or illness@;PU4.8,18;LBMo.@;PU5.7,18;LBDay@;"
 W !,"PU6.7,18;LBYr.@;PU.9,17.7;LBwas caused or aggravated@;PU.9,17.4;LBby your employment@;"
 W !,"PU4.7,17.4;PD7.3,17.4;PU4.7,17.4;PD4.7,17.6;PU5.6,17.4;PD5.6,17.6;PU6.4,17.4;PD6.4,17.6;PU7.3,17.4;PD7.3,17.6;"
 W !,"PU7.4,18.6;PD7.4,17.3;PD.5,17.3;PU7.5,18.3;LB13. Explain the relationship@;"
 W !,"LB to your employment, and why you came to this realization@;"
 W !,"PU.4,14.5;PD15.7,14.5;PU15.7,13.8;EA21,14.5;PU15.7,12.8;EA17.9,13.8;RA21,14.5;PU17.9,12.8;EA21,13.8;"
 W !,"PU.4,14.2;LB14. Nature of disease or illness@;PU15.8,14.2;SD1,277,2,1,4,9,5,0,6,1,7,23;LBOWCP Use - NOI Code@;"
 W !,"PU15.8,13.5;LBb. Type code@;PU18,13.5;LBc. Source code@;PU.4,12.8;PD15.7,12.8;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU.4,12.5;LB15. If this notice and claim was not filed with the employing agency within 30 days after date shown@;"
 W !,"LB above in item #12, explain the reason for the delay.@;PU.4,11;PD21,11;"
 W !,"PU.4,10.7;LB16. If the statement requested in item 1 of the attached instructions is not submitted@;"
 W !,"LB with this form, explain reason for delay.@;"
 W !,"PU.4,9.3;PD21,9.3;PU.4,9;LB17. If the medical reports requested in the item 2 of attached instructions@;"
 W !,"LB are not submitted with this form, explain reason for delay.@;"
 W !,"PU.4,7.6;PD21,7.6;PU.4,7.1;PD21,7.1;"
 W !,"PU.4,7.1;RA21,7.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,7.2;LBEmployee Signature@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
 W !,"PU.4,6.7;LB18. I certify, under penalty of law, that the disease or illness described above@;"
 W !,"LB was the result of my employment with the United States@;"
 W !,"PU.9,6.4;LBGovernment, and that it was not caused by my willful misconduct, intent to injure@;"
 W !,"LB myself or another person, nor by my intoxication.@;"
 W !,"PU.9,6.1;LBI hereby claim medical treatment, if needed, and other benefits provided@;"
 W !,"LB by the Federal Employees' Compensation Act.@;"
 W !,"PU.9,5.5;LBI hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any@;"
 W !,"PU.9,5.2;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative).@;"
 W !,"PU.9,4.9;LBThis authorization also permits any official representative of the Office to examine and to copy any records concerning me.@;"
 W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,4.4;LBSignature of employee or person acting on his/her behalf@;PU8.8,4.4;PD21,4.4;"
 W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU16.3,4.5;LBDate@;"
 W !,"PU.4,3.9;LBHave your supervisor complete the receipt attached to this form and return it to you for your records.@;"
 W !,"PU.4,3.4;LBAny person who knowingly makes any false statement, misrepresentation,@;"
 W !,"LB concealment of fact, or any other act of fraud to obtain compensation@;"
 W !,"PU.4,3.1;LBas provided by the FECA or who knowingly accepts compensation to which@;"
 W !,"LB that person is not entitled, is subject to civil or administrative remedies@;"
 W !,"PU.4,2.8;LBas well as felony criminal prosecution and may, under appropriate provisions, be punished by a fine or imprisonment, or both.@;"
 W !,"PU.4,2.6;PD21,2.6;"
 W !,"PU18.5,2.2;LBForm CA-2@;PU18.5,1.8;LBRev. Jan. 1997@;"
 D:IEN>0 ^OOPSPC41
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