OOPSPC71 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-1 (PART 2) ;5/8/98 ;;2.0;ASISTS;;Jun 03, 2002 EN1 ; W !,"PU.5,18.5;LBIf the employing agency controverts COP, the employee should#;" W !,"PU11,18.4;LBa) The disability was not caused by a traumatic injury.#;" W !,"PU.5,18.2;LBbe notified and the reason for controversion explained to him or#;" W !,"PU.5,17.9;LBher.#;" W !,"PU11,17.7;LBb) The employee is a volunteer working without pay or for#;" W !,"PU11.5,17.4;LBnominal pay, or a member of the office staff of a former#;" W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,17.2;LB17) Agency name and address of reporting office#;SD1,277,2,1,4,9,5,0,6,0,7,16901;" W !,"PU11.5,17.1;LBPresident;#;" W !,"PU.5,16.7;LBThe name and address of the office to which correspondence#;" W !,"PU11,16.6;LBc) The employee is not a citizen or a resident of the United#;" W !,"PU.5,16.4;LBfrom OWCP should be sent (if applicable, the address of the#;" W !,"PU11.5,16.3;LBStates or Canada;#;" W !,"PU.5,16.1;LBpersonnel or compensation office).#;" W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,15.5;LB18) Duty station street address and zip code#;SD1,277,2,1,4,9,5,0,6,0,7,16901;" W !,"PU11,15.6;LBd) The injury occurred off the employing agency's premises and#;" W !,"PU11.5,15.3;LBthe employee was not involved in official ""off premise"" duties;#;" W !,"PU.5,15;LBThe address and zip code of the establishment where the#;" W !,"PU.5,14.7;LBemployee actually works.#;" W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,14.1;LB19) Employers Retirement Coverage.#;SD1,277,2,1,4,9,5,0,6,0,7,16901;" W !,"PU.5,13.7;LBIndicate which retirement system the employee is covered under.#;" W !,"PU11,14.5;LBe) The injury was proximately caused by the employee's willful#;" W !,"PU11.5,14.2;LBmisconduct, intent to bring about injury or death to self or#;" W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LB30) Was injury caused by third party?#;SD1,277,2,1,4,9,5,0,6,0,7,16901;" W !,"PU11.5,13.9;LBanother person, or intoxication;#;" W !,"PU.5,12.4;LBA third party is an individual or organization (other than the#;" W !,"PU.5,12.1;LBinjured employee or the Federal government) who is liable for#;" W !,"PU11,13.1;LBf) The injury was not reported on Form CA-1 within 30 days#;" W !,"PU.5,11.8;LBthe injury. For instance, the driver of a vehicle causing an#;" W !,"PU11.5,12.8;LBfollowing the injury;#;" W !,"PU.5,11.5;LBaccident in which an employee is injured, the owner of a#;" W !,"PU.5,11.2;LBbuilding where unsafe conditions cause an employee to fall, and#;" W !,"PU11,12.1;LBg) Work stoppage first occurred 45 days or more following#;" W !,"PU.5,10.9;LBa manufacturer whose defective product causes an employee's#;" W !,"PU11.5,11.8;LBthe injury;#;" W !,"PU.5,10.6;LBinjury, could all be considered third parties to the injury.#;" W !,"PU11,11.1;LBh) The employee initially reported the injury after his or her#;" W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,9.8;LB32) Name and address of physician first providing#;PU.5,9.4;LBmedical care#;" W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11.5,10.8;LBemployment was terminated; or#;" W !,"PU11,10.1;LBi) The employee is enrolled in the Civil Air Patrol, Peace Corps,#;" W !,"PU.5,8.9;LBThe name and address of the physician who first provided#;" W !,"PU11.5,9.8;LBYouth Conservation Corps, Work Study Programs, or other#;" W !,"PU.5,8.6;LBmedical care for this injury. If initial care was given by a nurse#;" W !,"PU11.5,9.5;LBsimilar groups.#;" W !,"PU.5,8.3;LBor other health professional (not a physician) in the employing#;" W !,"PU.5,8;LBagency's health unit or clinic, indicate this on a separate sheet#;" W !,"PU.5,7.7;LBof paper.#;" W !,"PU.5,6.6;EA21,7.1;RA21,7.1;PU.6,6.7;SD1,277,2,1,4,9,5,0,6,2,7,23;" W !,"PU.6,6.7;LBEmploying Agency - Required Codes#;" W !,"PU.5,6.2;LBBox a (Occupation Code), Box b (Type Code),#;" W !,"PU.5,5.8;LBBox c (Source Code), OSHA Site Code#;PU11,6.2;LBOWCP Agency Code#;" W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11,5.6;LBThis is a four-digit (or four digit plus two letter) code used by#;" W !,"PU.5,5.3;LBThe Occupational Safety and Health Administration (OSHA)#;" W !,"PU11,5.3;LBOWCP to identify the employing agency. The proper code may#;" W !,"PU.5,5;LBrequires all employing agencies to complete these items when#;" W !,"PU11,5;LBbe obtained from your personnel or compensation office, or by#;" W !,"PU.5,4.7;LBreporting an injury. The proper codes may be found in OSHA#;" W !,"PU11,4.7;LBcontacting OWCP.#;" W !,"PU.5,4.4;LBBooklet 2014, Recordkeeping and Reporting Guidelines.#;" W !,"PU.5,4;PD21,4;PU18,3.5;LBForm CA-1#;PU18,3;LBRev. Apr. 1999#;" Q