| [628] | 1 | OOPSPC80 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-2 (PART 1) ;5/4/98
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| 2 | ;;2.0;ASISTS;;Jun 03, 2002
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| 3 | EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
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| 4 | W !,$CHAR(27),"E",$CHAR(27),"&l1E",$CHAR(27),"*c5952x7920Y",$CHAR(27),"%0B",$CHAR(27),"&s1#C"
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| 5 | W !,"IN;SP1;IP;PW.2;SC0,22,0,29,1;"
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| 6 | W !,"DT@,1;SD1,277,2,1,4,10,5,0,6,2,7,23;"
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| 7 | W !,"PU.5,28.3;LBInstructions for Completing Form CA-2@;"
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| 8 | W !,"PU.5,28.1;PD22,28.1;"
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| 9 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.7;LBComplete all items on your section of the form. If additional space is required @;"
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| 10 | W !,"LBto explain or clarify any point, attach a supplemental@;"
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| 11 | W !,"PU0.5,27.4;LBstatement to the form. In addition to the information requested on the form, both the employee @;"
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| 12 | W !,"LBand the supervisor are required to @;"
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| 13 | W !,"PU0.5,27.1;LBsubmit additional evidence as decribed below. If this evidence is not submitted @;"
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| 14 | W !,"LBalong with the form, the responsible party should@;"
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| 15 | W !,"PU0.5,26.8;LBexplain the reason for the delay and state when the additional evidence will be submitted.@;"
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| 16 | W !,"PU.5,26.6;PD22,26.6;PU.5,26.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmployee@;"
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| 17 | W !,"LB (or person acting on the employee's behalf)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 18 | W !,"PU.5,26.1;PD22,26.1;PU.5,26.1;FT10,10;RA22,26.6;"
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| 19 | W !,"PU0.5,25.7;LBComplete items 1 through 18 and submit the form to the employee's supervisor @;"
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| 20 | W !,"LBalong with the statement and medical reports described@;"
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| 21 | W !,"PU0.5,25.4;LBbelow. Be sure to obtain the Receipt of Notice of Disease or Illness completed @;"
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| 22 | W !,"LBby the supervisor at the time the form is submitted.@;"
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| 23 | W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU0.5,25;LB1) Employee's statement@;"
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| 24 | W !,"PU11,25;LB2) Medical report@;"
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| 25 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU0.5,24.7;LBIn a separate narrative statement attached to the form the@;"
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| 26 | W !,"PU0.5,24.4;LBemployee must submit the following information:@;"
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| 27 | W !,"PU1,24;LBa) A detailed history of the disease or illness from the date it@;"
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| 28 | W !,"PU1.3,23.7;LBstarted.@;"
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| 29 | W !,"PU1,23.3;LBb) Complete details of the conditions of employment which are@;"
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| 30 | W !,"PU1.3,23;LBbelieved to be responsible for the disease or illness.@;"
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| 31 | W !,"PU1,22.6;LBc) A description of specific exposures to substances or stress-@;"
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| 32 | W !,"PU1.3,22.3;LBful conditions causing the disease or illness, including loca-@;"
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| 33 | W !,"PU1.3,22;LBtions where exposure or stress occurred, as well as the@;"
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| 34 | W !,"PU1.3,21.7;LBnumber of hours per day and days per week of such@;"
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| 35 | W !,"PU1.3,21.4;LBexposure or stress.@;"
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| 36 | W !,"PU1,21;LBd) Identification of the part of the body affected. (If disability is@;"
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| 37 | W !,"PU1.3,20.7;LBdue to a heart condition, give complete details of all@;"
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| 38 | W !,"PU1.3,20.4;LBactivities for one week prior to the attack with particular@;"
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| 39 | W !,"PU1.3,20.1;LBattention to the final 24 hours of such period.)@;"
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| 40 | W !,"PU1,19.7;LBe) A statement as to whether the employee ever suffered a@;"
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| 41 | W !,"PU1.3,19.4;LBsimilar condition. If so, provide full details of onset, history,@;"
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| 42 | W !,"PU1.3,19.1;LBand medical care received, along with names and addres-@;"
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| 43 | W !,"PU1.3,18.8;LBses of physicians rendering treatment.@;"
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| 44 | W !,"PU11.5,24.6;LBa) Dates of examination or treatment.@;"
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| 45 | W !,"PU11.5,24.2;LBb) History given to the physician by the employee.@;"
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| 46 | W !,"PU11.5,23.8;LBc) Detailed description of the physician's findings.@;"
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| 47 | W !,"PU11.5,23.4;LBd) Results of x-rays, laboratory tests, etc.@;"
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| 48 | W !,"PU11.5,23;LBe) Diagnosis.@;PU11.5,22.6;LBf) Clinical course of treatment.@;"
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| 49 | W !,"PU11.5,22.2;LBg) Physician's opinion as to whether the disease or illness@;"
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| 50 | W !,"PU11.8,21.9;LBwas caused or aggravated by the employment, along with@;"
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| 51 | W !,"PU11.8,21.6;LBan explanation of the basis for this opinion. (Medical@;"
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| 52 | W !,"PU11.8,21.3;LBreports that do not explain the basis for the physician's@;"
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| 53 | W !,"PU11.8,21;LBopinion are given very little weight in adjudicating the@;"
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| 54 | W !,"PU11.8,20.7;LBclaim.)@;SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20;LB3) Wage loss@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 55 | W !,"PU11.5,19.6;LBIf you have lost wages or used leave for this illness, Form@;PU11.5,19.3;LBCA-7 should also be submitted.@;"
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| 56 | W !,"PU.5,18.6;PD22,18.6;"
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| 57 | W !,"PU.5,18.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBSupervisor@;"
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| 58 | W !,"LB (Or appropriate official in the employing agency)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 59 | W !,"PU.5,18.1;PD22,18.1;PU.5,18.1;RA22,18.6;"
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| 60 | W !,"PU.5,17.7;LBAt the time the form is received, complete the Receipt of Notice of Disease or Illness and give @;"
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| 61 | W !,"LBit to the employee. In addition to completing@;"
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| 62 | W !,"PU.5,17.4;LBitems 19 through 34, the supervisor is responsible for filling in the proper codes @;"
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| 63 | W !,"LBin shaded boxes a, b, and c on the front of the form. If@;"
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| 64 | W !,"PU.5,17.1;LBmedical expense or lost time is incurred or expected, the completed form @;"
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| 65 | W !,"LBmust be sent to OWCP within ten working days after it is@;"
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| 66 | W !,"PU.5,16.8;LBreceived. In a separate, narrative statement attached to the form, the supervisor must:@;"
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| 67 | D ^OOPSPC81
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| 68 | W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
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