| [613] | 1 | OOPSPC10 ;HIRMFO/YH-FEDERAL EMPLOYEE'S NOTICE OF TRAUMATIC INJURY - EMPLOYEE ;2/19/98
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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.3;SC0,22,0,29,1;"
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| 6 | W !,"DT#,1;"
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| 7 | W !,"SD1,277,2,1,4,12,5,0,6,0,7,16901;PU1,28.6;LBFederal Employee's Notice of#;PU1,28.2;LBTraumatic Injury and Claim for#;"
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| 8 | W !,"PU1,27.8;LBContinuation of Pay/Compensation#;"
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| 9 | W !,"SD1,277,2,1,4,12,5,0,6,1,7,23;PU11,28.5;LBU.S. Department of Labor#;"
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| 10 | W !,"SD1,277,2,1,4,10,5,0,6,0,7,16901;PU11,28.1;LBEmployment Standards Administration#;"
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| 11 | W !,"PU11,27.8;LBOffice of Workers' Compensation Programs#;"
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| 12 | W !,"PU1,27.6;PD21,27.6;"
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| 13 | W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,27.3;LBEmployee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.#"
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| 14 | W !,"PU1,26.9;LBWitness: Complete bottom section 16.#;"
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| 15 | W !,"PU1,26.5;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.#;"
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| 16 | W !,"PU.9,26;FT10,10;RA21,26.4;EA21,26.4;PU1,26.1;LBEmployee Data#;"
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| 17 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,25.7;LB1. Name of employee (Last, First, Middle)#;"
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| 18 | W !,"PU16.5,25.7;LB2. Social Security Number#;PU1,25.2;PD21,25.2;PU16.4,26;PD16.4,25.2;"
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| 19 | W !,"PU1,24.9;LB3. Date of birth#;PU3.4,24.9;LBMo.#;PU4.3,24.9;LBDay#;PU5.3,24.9;LBYr.#;"
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| 20 | W !,"PU6.8,24.4;PD6.8,25.2;PU6.9,24.9;LB4. Sex#;PU10.2,25.2;PD10.2,24.4;PU10.3,24.9;LB5. Home telephone#;"
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| 21 | W !,"PU15,25.2;PD15,24.4;PU15.1,24.9;LB6. Grade as of#;"
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| 22 | W !,"PU3.3,24.5;PD5.9,24.5;PU3.3,24.5;PD3.3,24.7;PU4.1,24.5;PD4.1,24.7;PU5,24.5;PD5,24.7;PU5.9,24.5;PD5.9,24.7;"
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| 23 | W !,"PU7.2,24.5;EA7.4,24.7;PU7.6,24.5;LBMale#;PU8.6,24.5;EA8.8,24.7;PU9,24.5;LBFemale#;"
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| 24 | W !,"PU15.5,24.6;LBdate of injury#;"
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| 25 | W !,"PU17.5,24.6;LBLevel#;PU19.1,24.6;LBStep#;"
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| 26 | W !,"PU1,24.4;PD21,24.4;"
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| 27 | W !,"PU1,24.1;LB7. Employee's home mailing address (Include city, state, and ZIP code)#;PU1,23.4;PD16.4,23.4;"
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| 28 | W !,"PU16.5,24.1;LB8. Dependents#;PU16.9,23.6;EA17.1,23.8;PU17.3,23.6;LBWife, Husband#;"
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| 29 | W !,"PU16.9,23.2;EA17.1,23.4;PU17.3,23.2;LBChildren under 18 years#;"
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| 30 | W !,"PU16.9,22.8;EA17.1,23;PU17.3,22.8;LBOther#;"
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| 31 | W !,"PU1,23.4;PD16.4;PU16.4,24.4;PD16.4,22.4;"
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| 32 | W !,"PU.9,22;RA21,22.4;EA21,22.4;PU1,22.1;SD1,277,2,1,4,9,5,0,6,1,7,23;LBDescription of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 33 | W !,"PU1,21.7;LB9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)#;"
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| 34 | W !,"PU1,20.8;PD21,20.8;PU1,20.5;LB10. Date injury occurred#;PU4.6,19.6;PD4.6,20.8;PU7.7,19.6,PD7.7,20.8;PU11.2,19.6;PD11.2,20.8;"
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| 35 | W !,"PU4.7,20.5;LBTime#;PU7.8,20.5;LB11. Date of this notice#;PU11.3,20.5;LB12. Employee's occupation#;"
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| 36 | W !,"PU1.2,19.7;PD3.9,19.7;PU1.2,19.7;PD1.2,19.9;PU2.1,19.7;PD2.1,19.9;PU3,19.7;PD3,19.9;PU3.9,19.7;PD3.9,19.9;"
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| 37 | W !,"PU1.3,20.1;LBMo.#;PU2.2,20.1;LBDay#;PU3.1,20.1;LBYr.#;SD1,277,2,1,4,9,5,0,6,3,7,23;PU5.5,20;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 38 | W !,"PU6.5,20.1;EA6.7,20.3;PU6.9,20.1;LBa.m.#;PU6.5,19.7;EA6.7,19.9;PU6.9,19.7;LBp.m.#;"
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| 39 | W !,"PU8.1,19.7;PD10.8,19.7;PU8.1,19.7;PD8.1,19.9;PU9,19.7;PD9,19.9;PU9.8,19.7;PD9.8,19.9;PU10.8,19.7;PD10.8,19.9;"
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| 40 | W !,"PU8.2,20.1;LBMo.#;PU9.1,20.1;LBDay#;PU9.9,20.1;LBYr.#;"
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| 41 | ;
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| 42 | W !,"PU1,19.6;PD21,19.6;PU1,18.6;PD21,18.6;PU1,17.6;PD21,17.6;PU1,16.6;PD21,16.6;"
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| 43 | W !,"PW.5;PU16.3,18.6;RA21,15.6;EA21,15.6;PW.3;"
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| 44 | W !,"PU16.4,18.3;LBa. Occupation code#;PU16.4,17.3;LBb. Type code#;PU18.4,17.6;PD18.4,16.6;PU18.5,17.3;LBc. Source code#;"
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| 45 | W !,"PU16.4,16.3;LBOWCP Use - NOI Code#;"
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| 46 | W !,"PU1,19.3;LB13. Cause of injury (Describe what happened and why)#;"
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| 47 | W !,"PU1,17.3;LB14. Nature of injury (Identify both the injury and the part of body, e.g., fracture of left leg)#;"
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| 48 | W !,"PU.9,15.2;RA21,15.6;EA21,15.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,15.3;LBEmployee Signature#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 49 | W !,"PU1,14.9;LB15. I certify, under penalty of law, that the injury described above#;"
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| 50 | W !,"LB was sustained in performance of duty as an employee of the#;"
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| 51 | W !,"PU1.5,14.6;LBUnited States Government and that it was not caused by my willful misconduct#;"
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| 52 | W !,"LB, intent to injure myself or another person, nor by#;"
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| 53 | W !,"PU1.5,14.3;LBmy intoxication. I hereby claim medical treatment, if needed, and the following,#;"
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| 54 | W !,"LB as checked below, while disabled for work:#;"
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| 55 | W !,"PU1.5,13.5;EA1.7,13.7;PU1.9,13.5;LBa. Continuation of regular pay (COP) not to exceed 45#;"
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| 56 | W !,"LB days and compensation for wage loss if disability for work continues#;"
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| 57 | W !,"PU2.3,13.2;LBbeyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick#;"
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| 58 | W !,"PU2.3,12.9;LBor annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.#;"
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| 59 | W !,"PU1.5,12.4;EA1.7,12.6;PU1.9,12.4;LBb. Sick and/or Annual Leave#;"
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| 60 | W !,"PU1.7,11.9;LBI hereby authorize any physician or hospital (or any other person, institution,#;"
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| 61 | W !,"LB corporation, or government agency) to furnish any#;"
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| 62 | W !,"PU1.7,11.6;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation#;"
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| 63 | W !,"LB Programs (or to its official representative).#;"
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| 64 | W !,"PU1.7,11.3;LBThis authorization also permits any official representative of the Office#;"
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| 65 | W !,"LB to examine and to copy any records concerning me.#;"
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| 66 | W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,10.6;LBSignature of employee or person acting on his/her behalf#;PU9.3,10.6;PD21,10.6;"
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| 67 | W !,"PU16.8,10.7;LBDate#;"
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| 68 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,10.1;LBAny person who knowingly makes any false statement,#;"
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| 69 | W !,"LB misrepresentation, concealment of fact or any other act of fraud to obtain compensation#;"
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| 70 | W !,"PU1,9.8;LBas provided by the FECA or who knowingly accepts compensation to which that person is not#;"
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| 71 | W !,"LB entitled is subject to civil or administrative#;"
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| 72 | W !,"PU1,9.5;LBremedies as well as felony criminal prosecution and may, under appropriate criminal provisions,#;"
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| 73 | W !,"LB be punished by a fine or imprisonment or both.#;"
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| 74 | W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,8.9;LBHave your supervisor complete the receipt attached to this form#;"
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| 75 | W !,"LB and return it to you for your records.#;"
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| 76 | W !,"PU.9,8.2;RA21,8.6;EA21,8.6;PU1,8.3;LBWitness Statement#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 77 | W !,"PU1,7.9;LB16. Statement of witness (Describe what you saw, heard, or know about this injury)#;"
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| 78 | W !,"PU1,4.6;PD21,4.6;PU1,4.3;LBName of witness#;"
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| 79 | W !,"PU8.9,4.3;LBSignature of witness#;PU17.6,4.3;LBDate signed#;"
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| 80 | W !,"PU1,3.8;PD21,3.8;PU1,3.5;LBAddress#;PU8.9,3.5;LBCity#;PU13.6,3.5;LBState#;PU17.6,3.5;LBZIP Code#;"
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| 81 | W !,"PU1,3;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#;"
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| 82 | ;CALL TO EXTRACT DATA
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| 83 | D:IEN>0 ^OOPSPC11
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| 84 | W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
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