| 1 | OOPSPC60 ;HIRMFO/YH-REPORT OF ACCIDENT CA2 - PAGE 3 ;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;SD1,277,2,1,4,10,5,0,6,1,7,23;PU.5,28.6;PD21,28.6;"
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| 7 | W !,"PU.5,28.3;LBDisability Benefits for Employees under the Federal Employees' Compensation Act (FECA)@;"
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| 8 | W !,"PU.5,28.2;FT10,10;RA21,28.6;PU.5,28.2;PD21,28.2;"
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| 9 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 10 | W !,"PU.5,27.6;LBThe FECA, which is administered by the Office of Workers'@;"
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| 11 | W !,"PU10.9,27.6;LBThe first three days in a non-pay status are waiting days, and@;"
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| 12 | W !,"PU.5,27.3;LBCompensation Programs (OWCP), provides the following@;"
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| 13 | W !,"PU10.9,27.3;LBno compensation is paid for these days unless the period of@;"
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| 14 | W !,"PU.5,27;LBgeneral benefits for employment-related occupational disease@;"
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| 15 | W !,"PU10.9,27;LBdisability exceeds 14 calendar days, or the employee has@;"
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| 16 | W !,"PU.5,26.7;LBor illness:@;"
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| 17 | W !,"PU10.9,26.7;LBsuffered a permanent disability. Compensation for total disa-@;"
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| 18 | W !,"PU10.9,26.4;LBbility is generally paid at the rate of 2/3 of an employee's@;"
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| 19 | W !,"PU10.9,26.1;LBsalary if there are no dependents, or 3/4 of salary if there are@;"
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| 20 | W !,"PU10.9,25.8;LBone or more dependents.@;"
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| 21 | W !,"PU.5,26;LB(1) Full medical care from either Federal medical officers and@;"
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| 22 | W !,"PU1,25.7;LBhospitals, or private hospitals or physicians of the@;"
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| 23 | W !,"PU1,25.4;LBemployee's choice.@;"
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| 24 | W !,"PU.5,24.6;LB(2) Payment of compensation for total or partial wage loss.@;"
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| 25 | W !,"PU.5,23.9;LB(3) Payment of compensation for permanent impairment of@;"
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| 26 | W !,"PU1,23.6;LBcertain organs, members, or functions of the body (such as@;"
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| 27 | W !,"PU1,23.3;LBloss or loss of use of an arm or kidney, loss of vision, etc.),@;"
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| 28 | W !,"PU1,23;LBor for serious disfigurement of the head, face, or neck.@;"
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| 29 | W !,"PU.5,22.3;LB(4) Vocational rehabilitation and related services where@;"
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| 30 | W !,"PU1,22;LBnecessary.@;"
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| 31 | W !,"PU10.9,25.2;LBAn employee may use sick or annual leave rather than LWOP@;"
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| 32 | W !,"PU10.9,24.9;LBwhile disabled. The employee may repurchase leave used@;"
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| 33 | W !,"PU10.9,24.6;LBfor approved periods. Form CA-7b, available from the@;"
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| 34 | W !,"PU10.9,24.3;LBpersonnel office, should be studied BEFORE a decision is@;"
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| 35 | W !,"PU10.9,24.0;LBmade to use leave.@;"
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| 36 | W !,"PU10.9,23.4;LBIf an employee is in doubt about compensation benefits, the@;"
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| 37 | W !,"PU10.9,23.1;LBOWCP District Office servicing the employing agency should@;"
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| 38 | W !,"PU10.9,22.8;LBbe contacted. (Obtain the address from your employing@;"
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| 39 | W !,"PU10.9,22.5;LBagency.)@;"
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| 40 | W !,"PU10.9,21.9;LBFor additional information, review the regulations governing the@;"
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| 41 | W !,"PU10.9,21.6;LBadministration of the FECA (Code of Federal Regulations, Title@;"
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| 42 | W !,"PU10.9,21.3;LB20, Chapter 1) or Chapter 810 of the Office of Personnel@;"
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| 43 | W !,"PU10.9,21.0;LBManagement's Federal Personnel Manual.@;"
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| 44 | W !,"PU.5,20.2;PD21,20.2;PU.5,19.7;PD21,19.7;PU.5,19.8;SD1,277,2,1,4,10,5,0,6,1,7,23;LBPrivacy Act@;"
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| 45 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,19.7;RA21,20.2;"
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| 46 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 47 | W !,"PU.5,19.0;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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| 48 | W !,"PU.5,18.5;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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| 49 | W !,"PU.5,18.0;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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| 50 | W !,"PU.5,17.5;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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| 51 | W !,"PU.5,17.0;LBverified through computer matches or other appropriate means. (3) Information may be given to the Federal Agency which employed the@;"
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| 52 | W !,"PU.5,16.5;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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| 53 | W !,"PU.5,16.0;LBconsider issues relating to retention, rehire, or relevant matters. (4) Information may also be given to other Federal agencies, other@;"
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| 54 | W !,"PU.5,15.5;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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| 55 | W !,"PU.5,15.0;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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| 56 | W !,"PU.5,14.5;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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| 57 | W !,"PU.5,14.0;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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| 58 | W !,"PU.5,13.5;LBdetermine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to@;"
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| 59 | W !,"PU.5,13.0;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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| 60 | W !,"PU.5,12.5;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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| 61 | W !,"PU.5,12.0;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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| 62 | W !,"PU.5,11.5;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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| 63 | W !,"PU.5,11.0;LBof the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.@;"
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| 64 | W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,10.5;LBNote: This notice applies to all forms requesting information that you might receive from the Office in connection with the@;"
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| 65 | W !,"PU.5,10.0;LBprocessing and adjudication of the claim you filed under the FECA. @;"
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| 66 | W !,"SD1,277,2,1,4,10,5,0,6,1,7,23;PU.5,9.3;LBReceipt of Notice of Occupational Disease or Illness@;"
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| 67 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9.7;PD21,9.7;PU.5,9.2;PD21,9.2;"
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| 68 | W !,"PU.5,9.2;RA21,9.7;PU.5,8.7;LBThis acknowledges receipt of notice of disease or illness sustained by:@;"
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| 69 | W !,"PU.5,8.4;LB(Name of injured employee)@;"
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| 70 | W !,"PU.5,7.7;PD21,7.7;PU.5,7.4;LBI was first notified about this condition on (Mo., Day, Yr.)@;"
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| 71 | W !,"PU.5,6.9;PD21,6.9:PU.5,6.6;LBAt (Location)@;"
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| 72 | W !,"PU.5,5.5;PD21,5.5;PU.5,5.2;LBSignature of Official Superior@;"
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| 73 | W !,"PU9.4,5.2;LBTitle@;PU16.3,5.2;LBDate (Mo., Day, Yr.)@;"
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| 74 | W !,"PU.5,4.3;PD21,4.3;PU.5,4;LBThis receipt should be retained by the employee as a record that notice was filed.@;"
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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;"
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| 76 | W !,"PU18.5,2.5;LBForm CA-2@;PU18.5,2.1;LBRev. Jan. 1997@;"
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| 77 | W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
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