| [613] | 1 | OOPSPC30 ;HIRMFO/YH-FEDERAL eMPLOYEE'S NOTICE OF TRAUMATIC INJURY - RECEIPT ;2/23/98
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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;SD1,277,2,1,4,9,5,0,6,1,7,23;FT10,10;PU.5,27.5;RA21,28;EA21,28;"
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| 7 | W !,"PU.6,27.6;LBBenefits for Employees under the Federal Employees' Compensation Act (FECA)#;"
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| 8 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 9 | W !,"PU.5,27;LBThe FECA, which is administered by the Office of Workers'#;"
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| 10 | W !,"PU.5,26.7;LBCompensation Programs (OWCP), provides the following#;"
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| 11 | W !,"PU.5,26.4;LBbenefits for job-related traumatic injuries:#;"
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| 12 | W !,"PU.5,25.5;LB(1) Continuation of pay for disability resulting from traumatic,#;"
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| 13 | W !,"PU1,25.2;LBjob-related injury, not to exceed 45 calendar days. (To be#;"
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| 14 | W !,"PU1,24.9;LBeligible for continuation of pay, the employee, or someone#;"
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| 15 | W !,"PU1,24.6;LBacting on his/her behalf, must file Form CA-1 within 30 days#;"
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| 16 | W !,"PU1,24.3;LBfollowing the injury and provide medical evidence in support#;"
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| 17 | W !,"PU1,24;LBof disability within 10 days of submission of the CA-1. Where#;"
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| 18 | W !,"PU1,23.7;LBthe employing agency continues the employee's pay, the pay#;"
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| 19 | W !,"PU1,23.4;LBmust not be interrupted unless one of the provision's outlined#;"
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| 20 | W !,"PU1,23.1;LBin 20 CFR 10.222 apply.#;"
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| 21 | W !,"PU.5,22.6;LB(2) Payment of compensation for wage loss after the expiration#;"
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| 22 | W !,"PU1,22.3;LBof COP, if disability extends beyond such point, or if COP is not#;"
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| 23 | W !,"PU1,22.0;LBpayable. If disability continues after COP expires, Form CA-7,#;"
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| 24 | W !,"PU1,21.7;LBwith supporting medical evidence, must be filed with OWCP.#;"
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| 25 | W !,"PU1,21.4;LBto avoid interruption of income, the form should be filed on the#;"
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| 26 | W !,"PU1,21.1;LB40th day of the COP period.#;"
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| 27 | W !,"PU.5,20.6;LB(3) Payment of compensation for permanent impairment of#;"
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| 28 | W !,"PU1,20.3;LBcertain organs, members, or functions of the body (such as#;"
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| 29 | W !,"PU1,20.0;LBloss or loss of use of an arm or kidney, loss of vision, etc.),#;"
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| 30 | W !,"PU1,19.7;LBor for serious disfigurement of the head, face, or neck.#;"
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| 31 | W !,"PU10.9,25.5;LB(4) Vocational rehabilitation and related services where#;"
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| 32 | W !,"PU11.4,25.2;LBdirected by OWCP.#;"
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| 33 | W !,"PU10.9,24.1;LB(5) All necessary medical care from qualified medical providers.#;"
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| 34 | W !,"PU11.4,23.8;LBThe injured employee may choose the physician who provides#;"
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| 35 | W !,"PU11.4,23.5;LBinitial medical care. Generally, 25 miles from the place of#;"
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| 36 | W !,"PU11.4,23.2;LBinjury, place of employment, or employee's home is a reasonable#;"
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| 37 | W !,"PU11.4,22.9;LBdistance to travel for medical care.#;"
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| 38 | W !,"PU11.4,22.2;LBAn employee may use sick or annual leave rather than LWOP#;"
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| 39 | W !,"PU11.4,21.9;LBwhile disabled. The employee may repurchase leave used#;"
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| 40 | W !,"PU11.4,21.6;LBfor approved periods. Form CA-7b, available from the#;"
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| 41 | W !,"PU11.4,21.3;LBpersonnel office, should be studied BEFORE a decision#;"
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| 42 | W !,"PU11.4,21.0;LBis made to use leave.#;"
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| 43 | W !,"PU11.4,20.3;LBFor additional information, review the regulations governing#;"
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| 44 | W !,"PU11.4,20.0;LBthe administration of the FECA (Code of Federal Regulations,#;"
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| 45 | W !,"PU11.4,19.7;LBChapter 20, Part 10) or pamphlet CA-810.#;"
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| 46 | W !,"PU.5,18.4;EA21,18.9;RA21,18.9;PU.6,18.5;SD1,277,2,1,4,9,5,0,6,1,7,23;LBPrivacy Act#;"
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| 47 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 48 | W !,"PU.5,18.0;LBIn accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'#;"
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| 49 | W !,"PU.5,17.5;LBCompensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation#;"
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| 50 | W !,"PU.5,17.0;LBPrograms of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)#;"
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| 51 | W !,"PU.5,16.5;LBInformation which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be#;"
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| 52 | W !,"PU.5,16.0;LBverified through computer matches or other appropriate means. (3) Information may be given to the Federal Agency which employed the#;"
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| 53 | W !,"PU.5,15.5;LBclaimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to#;"
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| 54 | W !,"PU.5,15.0;LBconsider issues relating to retention, rehire, or relevant matters. (4) Information may also be given to other Federal agencies, other#;"
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| 55 | W !,"PU.5,14.5;LBgovernment entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. #;"
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| 56 | W !,"PU.5,14.0;LB(5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational#;"
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| 57 | W !,"PU.5,13.5;LBrehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be#;"
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| 58 | W !,"PU.5,13.0;LBgiven to the Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to#;"
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| 59 | W !,"PU.5,12.5;LBdetermine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to#;"
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| 60 | W !,"PU.5,12.0;LBpursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7)#;"
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| 61 | W !,"PU.5,11.5;LBDisclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and#;"
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| 62 | W !,"PU.5,11.0;LBother information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal#;"
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| 63 | W !,"PU.5,10.5;LBGovernment, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing#;"
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| 64 | W !,"PU.5,10.0;LBof the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.#;"
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| 65 | W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.5;LBNote: This notice applies to all forms requesting information that you might receive from the Office in connection with the#;"
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| 66 | W !,"PU.5,9.0;LBprocessing and adjudication of the claim you filed under the FECA. #;"
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| 67 | W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU.6,8;LBReceipt of Notice of Injury#;PU.5,7.9;RA21,8.4;EA21,8.4;"
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| 68 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 69 | W !,"PU.5,7.5;LBThis acknowledges receipt of notice of injury sustained by:#;"
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| 70 | W !,"PU.5,7.2;LB(Name of injured employee)#;"
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| 71 | W !,"PU.5,6.3;PD21,6.3;PU.5,6;LBWhich occurred on (Mo., Day, Yr.)#;"
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| 72 | W !,"PU.5,5.5;PD21,5.5:PU.5,5.2;LBAt (Location)#;"
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| 73 | W !,"PU.5,4.2;PD21,4.2;PU.5,3.9;LBSignature of Official Superior#;"
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| 74 | W !,"PU9.4,3.9;LBTitle#;PU16.3,3.9;LBDate (Mo., Day, Yr.)#;"
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| 75 | W !,"PU.5,3;PD21,3;PU19,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBForm CA-1#;PU19,2.1;LBRev. Apr. 1999#;"
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| 76 | W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
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