| 1 | OOPSPC71 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-1 (PART 2) ;5/8/98
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| 2 | ;;2.0;ASISTS;;Jun 03, 2002
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| 3 | EN1 ;
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| 4 | W !,"PU.5,18.5;LBIf the employing agency controverts COP, the employee should#;"
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| 5 | W !,"PU11,18.4;LBa) The disability was not caused by a traumatic injury.#;"
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| 6 | W !,"PU.5,18.2;LBbe notified and the reason for controversion explained to him or#;"
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| 7 | W !,"PU.5,17.9;LBher.#;"
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| 8 | W !,"PU11,17.7;LBb) The employee is a volunteer working without pay or for#;"
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| 9 | W !,"PU11.5,17.4;LBnominal pay, or a member of the office staff of a former#;"
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| 10 | 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;"
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| 11 | W !,"PU11.5,17.1;LBPresident;#;"
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| 12 | W !,"PU.5,16.7;LBThe name and address of the office to which correspondence#;"
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| 13 | W !,"PU11,16.6;LBc) The employee is not a citizen or a resident of the United#;"
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| 14 | W !,"PU.5,16.4;LBfrom OWCP should be sent (if applicable, the address of the#;"
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| 15 | W !,"PU11.5,16.3;LBStates or Canada;#;"
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| 16 | W !,"PU.5,16.1;LBpersonnel or compensation office).#;"
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| 17 | 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;"
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| 18 | W !,"PU11,15.6;LBd) The injury occurred off the employing agency's premises and#;"
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| 19 | W !,"PU11.5,15.3;LBthe employee was not involved in official ""off premise"" duties;#;"
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| 20 | W !,"PU.5,15;LBThe address and zip code of the establishment where the#;"
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| 21 | W !,"PU.5,14.7;LBemployee actually works.#;"
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| 22 | 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;"
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| 23 | W !,"PU.5,13.7;LBIndicate which retirement system the employee is covered under.#;"
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| 24 | W !,"PU11,14.5;LBe) The injury was proximately caused by the employee's willful#;"
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| 25 | W !,"PU11.5,14.2;LBmisconduct, intent to bring about injury or death to self or#;"
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| 26 | 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;"
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| 27 | W !,"PU11.5,13.9;LBanother person, or intoxication;#;"
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| 28 | W !,"PU.5,12.4;LBA third party is an individual or organization (other than the#;"
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| 29 | W !,"PU.5,12.1;LBinjured employee or the Federal government) who is liable for#;"
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| 30 | W !,"PU11,13.1;LBf) The injury was not reported on Form CA-1 within 30 days#;"
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| 31 | W !,"PU.5,11.8;LBthe injury. For instance, the driver of a vehicle causing an#;"
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| 32 | W !,"PU11.5,12.8;LBfollowing the injury;#;"
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| 33 | W !,"PU.5,11.5;LBaccident in which an employee is injured, the owner of a#;"
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| 34 | W !,"PU.5,11.2;LBbuilding where unsafe conditions cause an employee to fall, and#;"
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| 35 | W !,"PU11,12.1;LBg) Work stoppage first occurred 45 days or more following#;"
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| 36 | W !,"PU.5,10.9;LBa manufacturer whose defective product causes an employee's#;"
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| 37 | W !,"PU11.5,11.8;LBthe injury;#;"
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| 38 | W !,"PU.5,10.6;LBinjury, could all be considered third parties to the injury.#;"
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| 39 | W !,"PU11,11.1;LBh) The employee initially reported the injury after his or her#;"
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| 40 | 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#;"
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| 41 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11.5,10.8;LBemployment was terminated; or#;"
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| 42 | W !,"PU11,10.1;LBi) The employee is enrolled in the Civil Air Patrol, Peace Corps,#;"
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| 43 | W !,"PU.5,8.9;LBThe name and address of the physician who first provided#;"
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| 44 | W !,"PU11.5,9.8;LBYouth Conservation Corps, Work Study Programs, or other#;"
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| 45 | W !,"PU.5,8.6;LBmedical care for this injury. If initial care was given by a nurse#;"
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| 46 | W !,"PU11.5,9.5;LBsimilar groups.#;"
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| 47 | W !,"PU.5,8.3;LBor other health professional (not a physician) in the employing#;"
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| 48 | W !,"PU.5,8;LBagency's health unit or clinic, indicate this on a separate sheet#;"
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| 49 | W !,"PU.5,7.7;LBof paper.#;"
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| 50 | 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;"
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| 51 | W !,"PU.6,6.7;LBEmploying Agency - Required Codes#;"
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| 52 | W !,"PU.5,6.2;LBBox a (Occupation Code), Box b (Type Code),#;"
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| 53 | W !,"PU.5,5.8;LBBox c (Source Code), OSHA Site Code#;PU11,6.2;LBOWCP Agency Code#;"
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| 54 | 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#;"
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| 55 | W !,"PU.5,5.3;LBThe Occupational Safety and Health Administration (OSHA)#;"
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| 56 | W !,"PU11,5.3;LBOWCP to identify the employing agency. The proper code may#;"
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| 57 | W !,"PU.5,5;LBrequires all employing agencies to complete these items when#;"
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| 58 | W !,"PU11,5;LBbe obtained from your personnel or compensation office, or by#;"
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| 59 | W !,"PU.5,4.7;LBreporting an injury. The proper codes may be found in OSHA#;"
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| 60 | W !,"PU11,4.7;LBcontacting OWCP.#;"
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| 61 | W !,"PU.5,4.4;LBBooklet 2014, Recordkeeping and Reporting Guidelines.#;"
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| 62 | W !,"PU.5,4;PD21,4;PU18,3.5;LBForm CA-1#;PU18,3;LBRev. Apr. 1999#;"
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| 63 | Q
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