| [604] | 1 | English French Notes Complete/Exclude
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| 2 | PU14.1,18.8;PD16.7,18.8;PU14.1,18.8;PD14.1,19;PU14.9,18.8;PD14.9,19;PU15.8,18.8;PD15.8,19;PU16.7,18.8;PD16.7,19;PU.5,18.4;PD21,18.4;
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| 3 | PU.5,18.4;PD21,18.4;PU.5,18.1;LB30. Date@;PU2.6,18.1;LBMo.@;PU3.5,18.1;LBDay@;PU4.5,18.1;LBYr.#
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| 4 | PU1.1,17.8;LBreturned@;PU1.1,17.5;LBto work@;PU2.5,17.5;PD5.1,17.5;PU2.5,17.5;PD2.5,17.7;PU3.3,17.5;PD3.3,17.7;PU4.2,17.5;PD4.2,17.7;
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| 5 | PU5.1,17.5;PD5.1,17.7;PU5.4,17.5;LBTime@;SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.9,17.5;LB:@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 6 | PU7.8,17.7;EA8,17.9;PU8.2,17.7;LBa.m.@;PU7.8,17.3;EA8,17.5;PU8.2,17.3;LBp.m.@;
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| 7 | PU.5,17.1;PD21,17.1;PU.5,16.8;LB31. If employee has returned to work and work assignment has changed, describe new duties@;
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| 8 | PU.5,12.6;PD21,12.6;
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| 9 | PU.5,12.3;LB32. Was injury caused@;PU3.6,12.6;PD3.6,10.1;PU3.6,11.7;PD21,11.7;PU3.6,10.9;PD21,10.9;
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| 10 | PU3.7,12.3;LB33. Name and address of third party (Include city, state, and zip code)@;
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| 11 | PU.9,12;LBby third party?@;PU.9,11.5;EA1.1,11.7;PU1.3,11.5;LBYes@;PU2.3,11.5;EA2.5,11.7;PU2.7,11.5;LBNo@;
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| 12 | PU2.3,11.2;LBIf
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| 13 | No,
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| 14 | @;PU2.3,10.9;LBgo to@;PU2.3,10.6;LBitem 34.@;
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| 15 | PU.5,10.1;PD21,10.1;PU.5,9.6;PD21,9.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.7;LBSignature of Supervisor@;PU.5,9.6;RA21,10.1;
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| 16 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9.3;LB34. A supervisor who knowingly certifies to any false statement,@;
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| 17 | LB misrepresentation, concealment of fact, etc., in respect to this claim@;
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| 18 | PU1.1,8.9;LBmay also be subject to appropriate felony criminal prosecution.@;
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| 19 | PU1.1,8.4;LBI certify that the information given above and that furnished by the employee on the reverse@;
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| 20 | LB of this form is true to the best of my@;
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| 21 | PU1.1,8.1;LBknowledge with the following exception:@;
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| 22 | PU.5,6.2;PD21,6.2;PU.5,5.9;LBName of Supervisor (Type or print)@;
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| 23 | PU.5,5.4;PD21,5.4;PU.5,5.1;LB Signature of Supervisor@;PU12.4,5.1;LBDate@;
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| 24 | PU.5,4.6;PD21,4.6;PU.5,4.3;LBSupervisor's Title@;PU12.4,4.3;LBOffice phone@;
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| 25 | PU.5,3;PD21,3;PU19,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBCA-2@;
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| 26 | 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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| 27 | PU1,27.8;LBContinuation of Pay/Compensation#;
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| 28 | SD1,277,2,1,4,12,5,0,6,1,7,23;PU11,28.5;LBU.S. Department of Labor#;
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| 29 | SD1,277,2,1,4,10,5,0,6,0,7,16901;PU11,28.1;LBEmployment Standards Administration#;
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| 30 | PU11,27.8;LBOffice of Workers' Compensation Programs#;
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| 31 | PU1,27.6;PD21,27.6;
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| 32 | 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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| 33 | PU1,26.9;LBWitness: Complete bottom section 16.#;
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| 34 | PU1,26.5;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.#;
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| 35 | PU.9,26;FT10,10;RA21,26.4;EA21,26.4;PU1,26.1;LBEmployee Data#;
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| 36 | 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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| 37 | 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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| 38 | 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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| 39 | 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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| 40 | PU15,25.2;PD15,24.4;PU15.1,24.9;LB6. Grade as of#;
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| 41 | 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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| 42 | 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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| 43 | PU15.5,24.6;LBdate of injury#;
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| 44 | PU17.5,24.6;LBLevel#;PU19.1,24.6;LBStep#;
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| 45 | PU1,24.4;PD21,24.4;
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| 46 | 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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| 47 | PU16.5,24.1;LB8. Dependents#;PU16.9,23.6;EA17.1,23.8;PU17.3,23.6;LBWife, Husband#;
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| 48 | PU16.9,23.2;EA17.1,23.4;PU17.3,23.2;LBChildren under 18 years#;
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| 49 | PU16.9,22.8;EA17.1,23;PU17.3,22.8;LBOther#;
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| 50 | PU1,23.4;PD16.4;PU16.4,24.4;PD16.4,22.4;
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| 51 | 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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| 52 | PU1,21.7;LB9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)#;
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| 53 | 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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| 54 | 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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| 55 | 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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| 56 | 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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| 57 | 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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| 58 | 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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| 59 | PU8.2,20.1;LBMo.#;PU9.1,20.1;LBDay#;PU9.9,20.1;LBYr.#;
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| 60 | 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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| 61 | PW.5;PU16.3,18.6;RA21,15.6;EA21,15.6;PW.3;
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| 62 | 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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| 63 | PU16.4,16.3;LBOWCP Use - NOI Code#;
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| 64 | PU1,19.3;LB13. Cause of injury (Describe what happened and why)#;
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| 65 | 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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| 66 | 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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| 67 | PU1,14.9;LB15. I certify, under penalty of law, that the injury described above#;
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| 68 | LB was sustained in performance of duty as an employee of the#;
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| 69 | PU1.5,14.6;LBUnited States Government and that it was not caused by my willful misconduct#;
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| 70 | LB, intent to injure myself or another person, nor by#;
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| 71 | PU1.5,14.3;LBmy intoxication. I hereby claim medical treatment, if needed, and the following,#;
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| 72 | LB as checked below, while disabled for work:#;
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| 73 | 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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| 74 | LB days and compensation for wage loss if disability for work continues#;
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| 75 | 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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| 76 | PU2.3,12.9;LBor annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.#;
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| 77 | PU1.5,12.4;EA1.7,12.6;PU1.9,12.4;LBb. Sick and/or Annual Leave#;
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| 78 | PU1.7,11.9;LBI hereby authorize any physician or hospital (or any other person, institution,#;
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| 79 | LB corporation, or government agency) to furnish any#;
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| 80 | PU1.7,11.6;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation#;
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| 81 | LB Programs (or to its official representative).#;
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| 82 | PU1.7,11.3;LBThis authorization also permits any official representative of the Office#;
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| 83 | LB to examine and to copy any records concerning me.#;
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| 84 | 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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| 85 | PU16.8,10.7;LBDate#;
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| 86 | 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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| 87 | LB misrepresentation, concealment of fact or any other act of fraud to obtain compensation#;
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| 88 | PU1,9.8;LBas provided by the FECA or who knowingly accepts compensation to which that person is not#;
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| 89 | LB entitled is subject to civil or administrative#;
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| 90 | PU1,9.5;LBremedies as well as felony criminal prosecution and may, under appropriate criminal provisions,#;
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| 91 | LB be punished by a fine or imprisonment or both.#;
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| 92 | 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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| 93 | LB and return it to you for your records.#;
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| 94 | 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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| 95 | PU1,7.9;LB16. Statement of witness (Describe what you saw, heard, or know about this injury)#;
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| 96 | PU1,4.6;PD21,4.6;PU1,4.3;LBName of witness#;
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| 97 | PU8.9,4.3;LBSignature of witness#;PU17.6,4.3;LBDate signed#;
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| 98 | 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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| 99 | 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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| 100 | PU1.3,25.4,LB
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| 101 | PU16.8,25.3;LB
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| 102 | PU7.2,24.5;LBX#;
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| 103 | PU8.6,24.5;LBX#;
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| 104 | PU10.8,24.6;LB
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| 105 | PU18.4,24.6;LB
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| 106 | PU1.3,23.6;LB
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| 107 | PU1.3,22.6;LB
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| 108 | LB,
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| 109 | PU16.9,23.6;LBX#;
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| 110 | PU16.9,23.2;LBX#;
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| 111 | PU16.9,22.8;LBX#;
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| 112 | PU16.9,23.6;LBX#;PU16.9,23.2;LBX#;
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| 113 | PU16.9,23.6;LBX#;PU16.9,22.8;LBX#;
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| 114 | PU16.9,23.2;LBX#;PU16.9,22.8;LBX#;
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| 115 | PU16.9,23.6;LBX#;PU16.9,23.2;LBX#;PU16.9,22.8;LBX#;
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| 116 | PU1.3,21;LB
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| 117 | PU11.6,20;LB
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| 118 | PU1.3,18.8;LB
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| 119 | PU1.3,18.2;LB
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| 120 | PU1.3,17.8;LB
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| 121 | PU17.4,17.8;LB
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| 122 | PU1.3,16.8;LB
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| 123 | PU16.8,16.8;LB
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| 124 | PU18.9,16.8;LB
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| 125 | PU1.3,15.8;LB
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| 126 | PU16.8,15.8;LB
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| 127 | PU1.5,13.5;LBX#;
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| 128 | PU1.5,12.4;LBX#;
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| 129 | PU9.6,10.7;LB/ES/
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| 130 | PU17.6,10.7;LB
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| 131 | PU1.5,7.0;LB
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| 132 | PU1.5,3.9;LB
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| 133 | PU17.9,3.9;LB
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| 134 | PU1.5,3.2;LB
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| 135 | PU8.2,3.2;LB
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| 136 | PU13.4,3.2;LB
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| 137 | PU17.9,3.2;LB
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| 138 | PU1,3.9;LB
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| 139 | DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;
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| 140 | PU.5,28.8;LBOfficial Supervisor's Report: Please complete information requested below:#;
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| 141 | PU.4,28.2;FT10,10;RA21,28.6;EA21,28.6;PU.5,28.3;LBSupervisor's Report#;
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| 142 | PU.5,27.9;LB17. Agency name and address of reporting office (Include city, state, and ZIP code)#;
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| 143 | PU17,28.2;PD17,27.3;PU17.1,27.9;LBOWCP Agency Code#;
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| 144 | PU15.7,26.4;PD15.7,27.3;PU15.8,27;LBOSHA Site Code#;PU14.5,26.1;LBZIP Code#;
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| 145 | PU.5,26.1;LB18. Employee's duty station (Street address and ZIP code)#;
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| 146 | PU.5,25.3;LB19. Employee's retirement coverage#;
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| 147 | PU7.2,25.3;EA7.4,25.1;PU7.8,25.1;LBCSRS#
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| 148 | PU9.2,25.3;EA9.4,25.1;PU9.8,25.1;LBFERS#
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| 149 | PU11.2,25.3;EA11.4,25.1;PU11.8,25.1;LBOther, (Identify)#
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| 150 | PU.5,24.4;LB20. Regular#;PU1,24;LBwork#;PU1,23.6;LBhours#;PU2.2,23.6;LBFrom#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU3.4,23.6;LB:#;
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| 151 | PU4.1,24.2;EA4.3,24.4;PU4.5,24.2;LBa.m.#;PU4.1,23.7;EA4.3,23.9;PU4.5,23.7;LBp.m.#;PU5.8,23.6;LBTo#;
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| 152 | SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.8,23.6;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 153 | PU7.4,24.2;EA7.6,24.4;PU7.8,24.2;LBa.m.#;PU7.4,23.7;EA7.6,23.9;PU7.8,23.7;LBp.m.#;
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| 154 | PU8.9,24.7;PD8.9,23.4;PU9,24.4;LB21. Regular#;PU9.6,24;LBwork#;PU9.6,23.6;LBschedule#;
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| 155 | PU11,23.6;EA11.2,23.8;PU11.4,23.6;LBSun.#;PU12.3,23.6;EA12.5,23.8;PU12.7,23.6;LBMon.#;
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| 156 | PU13.6,23.6;EA13.8,23.8;PU14,23.6;LBTues.#;PU14.9,23.6;EA15.1,23.8;PU15.3,23.6;LBWed.#;
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| 157 | PU16.2,23.6;EA16.4,23.8;PU16.6,23.6;LBThurs.#;PU17.7,23.6;EA17.9,23.8;PU18.1,23.6;LBFri.#;
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| 158 | PU18.8,23.6;EA19,23.8;PU19.2,23.6;LBSat.#;
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| 159 | PU.5,23.4;PD21,23.4;PU.5,23.1;LB22. Date#;PU2.5,23.1;LBMo.#;PU3.5,23.1;LBDay#;PU4.5,23.1;LBYr.#;
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| 160 | PU5.6,23.4;PD5.6,22.4;PU5.7,23.1;LB23. Date#;PU8,23.1;LBMo.#;PU9,23.1;LBDay#;PU10,23.1;LBYr.#;
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| 161 | PU11,23.4;PD11,22.4;PU11.1,23.1;LB24. Date#;PU13.2,23.1;LBMo.#;PU14.2,23.1;LBDay#;PU15.2,23.1;LBYr.#;
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| 162 | PU1,22.8;LBof#;PU6.2,22.8;LBnotice#;PU11.6,22.8;LBstopped#;
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| 163 | PU1,22.5;LBinjury#;PU2.2,22.5;PD5.2,22.5;PU2.2,22.5;PD2.2,22.7;PU3.2,22.5;PD3.2,22.7;PU4.2,22.5;PD4.2,22.7;PU5.2,22.5;PD5.2,22.7;
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| 164 | PU6.2,22.5;LBreceived#;PU7.7,22.5;PD10.5,22.5;PU7.7,22.5;PD7.7,22.7;PU8.7,22.5;PD8.7,22.7;
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| 165 | PU9.7,22.5;PD9.7,22.7;PU10.5,22.5;PD10.5,22.7;
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| 166 | PU11.6,22.5;LBwork#;PU12.9,22.5;PD15.7,22.5;PU12.9,22.5;PD12.9,22.7;PU13.9,22.5;PD13.9,22.7;
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| 167 | PU14.8,22.5;PD14.8,22.7;PU15.7,22.5;PD15.7,22.7;
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| 168 | PU16,22.5;LBTime#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU17.2,22.5;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 169 | PU17.8,23;EA18,23.2;PU18.2,23;LBa.m.#;PU17.8,22.5;EA18,22.7;PU18.2,22.5;LBp.m.#;
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| 170 | PU.5,22.4;PD21,22.4;
|
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| 171 | PU.5,22.1;LB25.Date#;PU2.5,22.1;LBMo.#;PU3.5,22.1;LBDay#;PU4.5,22.1;LBYr.#;PU5.5,22.4;PD5.5,21.3;PU5.6,22.1;LB26.Date#;
|
|---|
| 172 | PU6.1,21.8;LB45 day#;
|
|---|
| 173 | PU8.4,22.1;LBMo.#;PU9.3,22.1;LBDay#;PU10.3,22.1;LBYr.#;PU11.3,22.4;PD11.3,21.3;PU11.4,22.1;LB27.Date#;
|
|---|
| 174 | PU13.4,22.1;LBMo.#;PU14.4,22.1;LBDay#;PU15.4,22.1;LBYr.#;
|
|---|
| 175 | PU1,21.8;LBpay#;PU1,21.5;LBstopped#;PU2.2,21.5;PD5.2,21.5;PU2.2,21.5;PD2.2,21.7;PU3.2,21.5;PD3.2,21.7;
|
|---|
| 176 | PU4.2,21.5;PD4.2,21.7;
|
|---|
| 177 | PU5.2,21.5;PD5.2,21.7;
|
|---|
| 178 | PU6.1,21.5;LBperiod began#;PU8.2,21.5;PD11,21.5;PU8.2,21.5;PD8.2,21.7;PU9.1,21.5;PD9.1,21.7;
|
|---|
| 179 | PU10.1,21.5;PD10.1,21.7;PU11,21.5;PD11,21.7;
|
|---|
| 180 | PU11.9,21.8;LBreturned#;PU11.9,21.5;LBto work#;PU13.2,21.5;PD16,21.5;PU13.2,21.5;PD13.2,21.7;
|
|---|
| 181 | PU14.2,21.5;PD14.2,21.7;PU15.2,21.5;PD15.2,21.7;
|
|---|
| 182 | PU16,21.5;PD16,21.7;PU16.3,21.5;LBTime#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU17.5,21.5;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
|
|---|
| 183 | PU18.2,21.9;EA18.4,22.1;PU18.6,21.9;LBa.m.#;PU18.2,21.5;EA18.4,21.7;PU18.6,21.5;LBp.m.#;
|
|---|
| 184 | PU.5,21.3;PD21,21.3;
|
|---|
| 185 | PU.5,21;LB28. Was employee injured in performance of duty?#
|
|---|
| 186 | PU7.6,21;EA7.8,21.2;PU8,21;LBYes#;PU9,21;EA9.2,21.2;PU9.4,21;LBNo#;PU10,21;LB(If
|
|---|
| 187 | PU.5,19.8;PD21,19.8;PU.5,19.5;LB29. Was injury caused by employee's willful misconduct, intoxication,#;
|
|---|
| 188 | LB or intent to injure self or another?#;
|
|---|
| 189 | PU15,19.5;EA15.2,19.7;PU15.4,19.5;LBYes#;PU16.2,19.5;LB(If
|
|---|
| 190 | Yes,
|
|---|
| 191 | PU19.2,19.5;EA19.4,19.7;PU19.6,19.5;LBNo#;
|
|---|
| 192 | PU.5,18.4;PD21,18.4;PU.5,18.1;LB30. Was injury caused#;PU4.2,18.4;PD4.2,15.8;PU4.2,17.6;PD21,17.6;PU4.2,16.7;PD21,16.7;
|
|---|
| 193 | PU4.3,18.1;LB31. Name and address of third party (Include city, state, and ZIP code)#;
|
|---|
| 194 | PU1,17.7;LBby third party?#;PU1,17.3;EA1.2,17.5;PU1.4,17.3;LBYes#;PU2.7,17.3;EA2.9,17.5;PU3.1,17.3;LBNo#;
|
|---|
| 195 | PU2.7,16.9;LB(If
|
|---|
| 196 | #;PU2.7,16.5;LBgo to#;PU2.7,16.1;LBitem 32.)#;
|
|---|
| 197 | PU.5,15.8;PD21,15.8;PU.5,15.5;LB32. Name and address of physician first providing medical care#;
|
|---|
| 198 | LB (Include city, state, ZIP code)#;
|
|---|
| 199 | PU14.5,15.8;PD14.5,13.1;PU14.6,15.5;LB33. First date#;PU17.1,15.4;LBMo.#;PU18.1,15.4;LBDay#;PU19.1,15.4;LBYr.#;
|
|---|
| 200 | PU15.1,15.2;LBmedical care#;PU15.1,14.9;LBreceived#;PU14.5,14.6;PD21,14.6;
|
|---|
| 201 | PU16.8,14.8;PD19.6,14.8;PU16.8,14.8;PD16.8,15;PU17.8,14.8;PD17.8,15;PU18.7,14.8;PD18.7,15;PU19.6,14.8;PD19.6,15;
|
|---|
| 202 | PU14.6,14.3;LB34. Do medical#;PU15.1,14;LBreports show#;PU15.1,13.7;LBemployee is#;PU15.1,13.4;LBdisabled for work?#;
|
|---|
| 203 | PU17.4,14.1;EA17.6,14.3;PU17.8,14.1;LBYes#;PU18.8,14.1;EA19,14.3;PU19.2,14.1;LBNo#;
|
|---|
| 204 | PU.5,14.8;PD14.5,14.8;PU.5,13.9;PD14.5,13.9;PU.5,13.1;PD21,13.1;PU14.5,15.8;PU14.5,13.1;
|
|---|
| 205 | PU.5,12.8;LB35. Does your knowledge of the facts about this injury agree with statements#;
|
|---|
| 206 | LB of the employee and/or witness?#;
|
|---|
| 207 | PU15.8,12.7;EA16,12.9;PU16.2,12.7;LBYes#;PU17.1,12.7;EA17.3,12.9;PU17.5,12.7;LBNo (If
|
|---|
| 208 | PU.5,11.3;PD21,11.3;PU.5,11;LB36. If the employing agency controverts continuation of pay, state the reason in detail.#;
|
|---|
| 209 | PU14.3,9.7;PD14.3,11.3;PU14.4,11;LB37. Pay rate#;PU15,10.7;LBwhen employee#;PU15,10.4;LBstopped work#;
|
|---|
| 210 | PU15,9.9;LB$#;PU17.9,9.9;LBPer#;
|
|---|
| 211 | PU.5,9.3;RA21,9.7;EA21,9.7;
|
|---|
| 212 | PU.5,9.2;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.4;LBSignature of Supervisor and Filing instructions#;
|
|---|
| 213 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9;LB38. A supervisor who knowingly certifies to any false statement,#;
|
|---|
| 214 | PU1.1,8.6;LBmay also be subject to appropriate felony criminal prosecution.#;
|
|---|
| 215 | PU1.1,7.9;LBI certify that the information given above and that furnished by the employee on the reverse#;
|
|---|
| 216 | LB of this form is true to the best of my#;
|
|---|
| 217 | PU1.1,7.6;LBknowledge with the following exception:#;
|
|---|
| 218 | PU.5,6.8;PD21,6.8;PU.5,6.5;LBName of supervisor (Type or print)#;
|
|---|
| 219 | PU.5,6.1;PD21,6.1;PU.5,5.8;LB Signature of supervisor#;PU12.9,5.8;LBDate#;
|
|---|
| 220 | PU.5,5.3;PD21,5.3;PU.5,5;LBSupervisor's Title#;PU12.9,5;LBOffice phone#;
|
|---|
| 221 | PU.5,4.6;PD21,4.6;PU.5,4.3;LB39. Filing instructions#;
|
|---|
| 222 | PU4.7,3.9;EA4.9,4.1;PU5.1,4.3;LBNo lost time and no medical expense: Place this form in employee's medical folder (SF-66-D)#;
|
|---|
| 223 | PU4.7,4.3;EA4.9,4.5;PU5.1,3.9;LBNo lost time, medical expense incurred or expected: forward this form to OWCP#;
|
|---|
| 224 | PU4.7,3.5;EA4.9,3.7;PU5.1,3.5;LBLost time covered by leave, LWOP, or COP: forward this form to OWCP#;
|
|---|
| 225 | PU4.7,3.1;EA4.9,3.3;PU5.1,3.1;LBFirst Aid injury#;
|
|---|
| 226 | PU.5,3;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#;
|
|---|
| 227 | PU1,27.4;LB
|
|---|
| 228 | PU17.7,27.4;LB
|
|---|
| 229 | PU1,26.6;LB
|
|---|
| 230 | PU1,25.7;LB
|
|---|
| 231 | PU7.2,25.1;LBX#;
|
|---|
| 232 | PU9.2,25.1;LBX#
|
|---|
| 233 | PU11.2,25.1;LBX#;
|
|---|
| 234 | PU1,24.8;LB
|
|---|
| 235 | PU3,23.6;LB
|
|---|
| 236 | PU4.1,24.2;LBX#;
|
|---|
| 237 | PU4.1,23.7;LBX#;
|
|---|
| 238 | PU6.3,23.6;LB
|
|---|
| 239 | PU7.4,24.2;LBX#;
|
|---|
| 240 | PU7.4,23.7;LBX#;
|
|---|
| 241 | PU7.6,21;LBX#;
|
|---|
| 242 | PU9,21;LBX#;
|
|---|
| 243 | PU1,20;LB
|
|---|
| 244 | PU15,19.5;LBX#;
|
|---|
| 245 | PU19.2,19.5;LBX#;
|
|---|
| 246 | PU1,18.6;LB
|
|---|
| 247 | PU1,17.3;LBX#;
|
|---|
| 248 | PU2.7,17.3;LBX#;
|
|---|
| 249 | PU4.3,17.7;LB
|
|---|
| 250 | PU4.3,16.8;LB
|
|---|
| 251 | PU4.3,15.9;LB
|
|---|
| 252 | PU1,15;LB
|
|---|
| 253 | PU1,14.1;LB
|
|---|
| 254 | PU1,13.3;LB
|
|---|
| 255 | PU17.4,14.1;LBX#;
|
|---|
| 256 | PU18.8,14.1;LBX#;
|
|---|
| 257 | PU15.8,12.7;LBX#;
|
|---|
| 258 | PU17.1,12.7;LBX#;
|
|---|
| 259 | PU1,12.4;LB
|
|---|
| 260 | PU1,12;LB
|
|---|
| 261 | PU1,11.6;LB
|
|---|
| 262 | PU1,12.3;LBSee Attached#;
|
|---|
| 263 | 35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witness?
|
|---|
| 264 | PU1,10.6;LB
|
|---|
| 265 | PU1,10.2;LB
|
|---|
| 266 | PU1,9.8;1LB
|
|---|
| 267 | PU1,10.5;LBSee Attached#;
|
|---|
| 268 | 36. If the employing agency controverts continuation of pay, state the reason in detail.
|
|---|
| 269 | PU15.2,9.9;LB
|
|---|
| 270 | PU1,7.1;LB
|
|---|
| 271 | PU1,6.2;LB
|
|---|
| 272 | PU1,5.4;LB/ES/
|
|---|
| 273 | PU12.9,5.4;LB
|
|---|
| 274 | PU1,4.7;LB
|
|---|
| 275 | PU4.7,4.3;LBX#;
|
|---|
| 276 | PU4.7,3.9;LBX#;
|
|---|
| 277 | PU4.7,3.5;LBX#;
|
|---|
| 278 | PU4.7,3.1;LBX#;
|
|---|
| 279 | DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;FT10,10;PU.5,27.5;RA21,28;EA21,28;
|
|---|
| 280 | PU.6,27.6;LBBenefits for Employees under the Federal Employees' Compensation Act (FECA)#;
|
|---|
| 281 | PU.5,27;LBThe FECA, which is administered by the Office of Workers'#;
|
|---|
| 282 | PU.5,26.7;LBCompensation Programs (OWCP), provides the following#;
|
|---|
| 283 | PU.5,26.4;LBbenefits for job-related traumatic injuries:#;
|
|---|
| 284 | PU.5,25.5;LB(1) Continuation of pay for disability resulting from traumatic,#;
|
|---|
| 285 | PU1,25.2;LBjob-related injury, not to exceed 45 calendar days. (To be#;
|
|---|
| 286 | PU1,24.9;LBeligible for continuation of pay, the employee, or someone#;
|
|---|
| 287 | PU1,24.6;LBacting on his/her behalf, must file Form CA-1 within 30 days#;
|
|---|
| 288 | PU1,24.3;LBfollowing the injury and provide medical evidence in support#;
|
|---|
| 289 | PU1,24;LBof disability within 10 days of submission of the CA-1. Where#;
|
|---|
| 290 | PU1,23.7;LBthe employing agency continues the employee's pay, the pay#;
|
|---|
| 291 | PU1,23.4;LBmust not be interrupted unless one of the provision's outlined#;
|
|---|
| 292 | PU1,23.1;LBin 20 CFR 10.222 apply.#;
|
|---|
| 293 | PU.5,22.6;LB(2) Payment of compensation for wage loss after the expiration#;
|
|---|
| 294 | PU1,22.3;LBof COP, if disability extends beyond such point, or if COP is not#;
|
|---|
| 295 | PU1,22.0;LBpayable. If disability continues after COP expires, Form CA-7,#;
|
|---|
| 296 | PU1,21.7;LBwith supporting medical evidence, must be filed with OWCP.#;
|
|---|
| 297 | PU1,21.4;LBto avoid interruption of income, the form should be filed on the#;
|
|---|
| 298 | PU1,21.1;LB40th day of the COP period.#;
|
|---|
| 299 | PU.5,20.6;LB(3) Payment of compensation for permanent impairment of#;
|
|---|
| 300 | PU1,20.3;LBcertain organs, members, or functions of the body (such as#;
|
|---|
| 301 | PU1,20.0;LBloss or loss of use of an arm or kidney, loss of vision, etc.),#;
|
|---|
| 302 | PU1,19.7;LBor for serious disfigurement of the head, face, or neck.#;
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
