source: internationalization/trunk/TranslationSpreadsheets/WV-DIALOG-0252.txt@ 1490

Last change on this file since 1490 was 604, checked in by George Lilly, 15 years ago

Internationalization
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1English French Notes Complete/Exclude
2PU14.1,18.8;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;
3PU.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.#
4PU1.1,17.8;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;
5PU5.1,17.5;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;
6PU7.8,17.7;EA8,17.9;PU8.2,17.7;LBa.m.@;PU7.8,17.3;EA8,17.5;PU8.2,17.3;LBp.m.@;
7PU.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@;
8PU.5,12.6;PD21,12.6;
9PU.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;
10PU3.7,12.3;LB33. Name and address of third party (Include city, state, and zip code)@;
11PU.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@;
12PU2.3,11.2;LBIf
13No,
14@;PU2.3,10.9;LBgo to@;PU2.3,10.6;LBitem 34.@;
15PU.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;
16SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9.3;LB34. A supervisor who knowingly certifies to any false statement,@;
17LB misrepresentation, concealment of fact, etc., in respect to this claim@;
18PU1.1,8.9;LBmay also be subject to appropriate felony criminal prosecution.@;
19PU1.1,8.4;LBI certify that the information given above and that furnished by the employee on the reverse@;
20LB of this form is true to the best of my@;
21PU1.1,8.1;LBknowledge with the following exception:@;
22PU.5,6.2;PD21,6.2;PU.5,5.9;LBName of Supervisor (Type or print)@;
23PU.5,5.4;PD21,5.4;PU.5,5.1;LB Signature of Supervisor@;PU12.4,5.1;LBDate@;
24PU.5,4.6;PD21,4.6;PU.5,4.3;LBSupervisor's Title@;PU12.4,4.3;LBOffice phone@;
25PU.5,3;PD21,3;PU19,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBCA-2@;
26SD1,277,2,1,4,12,5,0,6,0,7,16901;PU1,28.6;LBFederal Employee's Notice of#;PU1,28.2;LBTraumatic Injury and Claim for#;
27PU1,27.8;LBContinuation of Pay/Compensation#;
28SD1,277,2,1,4,12,5,0,6,1,7,23;PU11,28.5;LBU.S. Department of Labor#;
29SD1,277,2,1,4,10,5,0,6,0,7,16901;PU11,28.1;LBEmployment Standards Administration#;
30PU11,27.8;LBOffice of Workers' Compensation Programs#;
31PU1,27.6;PD21,27.6;
32SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,27.3;LBEmployee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.#
33PU1,26.9;LBWitness: Complete bottom section 16.#;
34PU1,26.5;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.#;
35PU.9,26;FT10,10;RA21,26.4;EA21,26.4;PU1,26.1;LBEmployee Data#;
36SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,25.7;LB1. Name of employee (Last, First, Middle)#;
37PU16.5,25.7;LB2. Social Security Number#;PU1,25.2;PD21,25.2;PU16.4,26;PD16.4,25.2;
38PU1,24.9;LB3. Date of birth#;PU3.4,24.9;LBMo.#;PU4.3,24.9;LBDay#;PU5.3,24.9;LBYr.#;
39PU6.8,24.4;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#;
40PU15,25.2;PD15,24.4;PU15.1,24.9;LB6. Grade as of#;
41PU3.3,24.5;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;
42PU7.2,24.5;EA7.4,24.7;PU7.6,24.5;LBMale#;PU8.6,24.5;EA8.8,24.7;PU9,24.5;LBFemale#;
43PU15.5,24.6;LBdate of injury#;
44PU17.5,24.6;LBLevel#;PU19.1,24.6;LBStep#;
45PU1,24.4;PD21,24.4;
46PU1,24.1;LB7. Employee's home mailing address (Include city, state, and ZIP code)#;PU1,23.4;PD16.4,23.4;
47PU16.5,24.1;LB8. Dependents#;PU16.9,23.6;EA17.1,23.8;PU17.3,23.6;LBWife, Husband#;
48PU16.9,23.2;EA17.1,23.4;PU17.3,23.2;LBChildren under 18 years#;
49PU16.9,22.8;EA17.1,23;PU17.3,22.8;LBOther#;
50PU1,23.4;PD16.4;PU16.4,24.4;PD16.4,22.4;
51PU.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;
52PU1,21.7;LB9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)#;
53PU1,20.8;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;
54PU4.7,20.5;LBTime#;PU7.8,20.5;LB11. Date of this notice#;PU11.3,20.5;LB12. Employee's occupation#;
55PU1.2,19.7;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;
56PU1.3,20.1;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;
57PU6.5,20.1;EA6.7,20.3;PU6.9,20.1;LBa.m.#;PU6.5,19.7;EA6.7,19.9;PU6.9,19.7;LBp.m.#;
58PU8.1,19.7;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;
59PU8.2,20.1;LBMo.#;PU9.1,20.1;LBDay#;PU9.9,20.1;LBYr.#;
60PU1,19.6;PD21,19.6;PU1,18.6;PD21,18.6;PU1,17.6;PD21,17.6;PU1,16.6;PD21,16.6;
61PW.5;PU16.3,18.6;RA21,15.6;EA21,15.6;PW.3;
62PU16.4,18.3;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#;
63PU16.4,16.3;LBOWCP Use - NOI Code#;
64PU1,19.3;LB13. Cause of injury (Describe what happened and why)#;
65PU1,17.3;LB14. Nature of injury (Identify both the injury and the part of body, e.g., fracture of left leg)#;
66PU.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;
67PU1,14.9;LB15. I certify, under penalty of law, that the injury described above#;
68LB was sustained in performance of duty as an employee of the#;
69PU1.5,14.6;LBUnited States Government and that it was not caused by my willful misconduct#;
70LB, intent to injure myself or another person, nor by#;
71PU1.5,14.3;LBmy intoxication. I hereby claim medical treatment, if needed, and the following,#;
72LB as checked below, while disabled for work:#;
73PU1.5,13.5;EA1.7,13.7;PU1.9,13.5;LBa. Continuation of regular pay (COP) not to exceed 45#;
74LB days and compensation for wage loss if disability for work continues#;
75PU2.3,13.2;LBbeyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick#;
76PU2.3,12.9;LBor annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.#;
77PU1.5,12.4;EA1.7,12.6;PU1.9,12.4;LBb. Sick and/or Annual Leave#;
78PU1.7,11.9;LBI hereby authorize any physician or hospital (or any other person, institution,#;
79LB corporation, or government agency) to furnish any#;
80PU1.7,11.6;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation#;
81LB Programs (or to its official representative).#;
82PU1.7,11.3;LBThis authorization also permits any official representative of the Office#;
83LB to examine and to copy any records concerning me.#;
84SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,10.6;LBSignature of employee or person acting on his/her behalf#;PU9.3,10.6;PD21,10.6;
85PU16.8,10.7;LBDate#;
86SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,10.1;LBAny person who knowingly makes any false statement,#;
87LB misrepresentation, concealment of fact or any other act of fraud to obtain compensation#;
88PU1,9.8;LBas provided by the FECA or who knowingly accepts compensation to which that person is not#;
89LB entitled is subject to civil or administrative#;
90PU1,9.5;LBremedies as well as felony criminal prosecution and may, under appropriate criminal provisions,#;
91LB be punished by a fine or imprisonment or both.#;
92SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,8.9;LBHave your supervisor complete the receipt attached to this form#;
93LB and return it to you for your records.#;
94PU.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;
95PU1,7.9;LB16. Statement of witness (Describe what you saw, heard, or know about this injury)#;
96PU1,4.6;PD21,4.6;PU1,4.3;LBName of witness#;
97PU8.9,4.3;LBSignature of witness#;PU17.6,4.3;LBDate signed#;
98PU1,3.8;PD21,3.8;PU1,3.5;LBAddress#;PU8.9,3.5;LBCity#;PU13.6,3.5;LBState#;PU17.6,3.5;LBZIP Code#;
99PU1,3;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#;
100PU1.3,25.4,LB
101PU16.8,25.3;LB
102PU7.2,24.5;LBX#;
103PU8.6,24.5;LBX#;
104PU10.8,24.6;LB
105PU18.4,24.6;LB
106PU1.3,23.6;LB
107PU1.3,22.6;LB
108LB,
109PU16.9,23.6;LBX#;
110PU16.9,23.2;LBX#;
111PU16.9,22.8;LBX#;
112PU16.9,23.6;LBX#;PU16.9,23.2;LBX#;
113PU16.9,23.6;LBX#;PU16.9,22.8;LBX#;
114PU16.9,23.2;LBX#;PU16.9,22.8;LBX#;
115PU16.9,23.6;LBX#;PU16.9,23.2;LBX#;PU16.9,22.8;LBX#;
116PU1.3,21;LB
117PU11.6,20;LB
118PU1.3,18.8;LB
119PU1.3,18.2;LB
120PU1.3,17.8;LB
121PU17.4,17.8;LB
122PU1.3,16.8;LB
123PU16.8,16.8;LB
124PU18.9,16.8;LB
125PU1.3,15.8;LB
126PU16.8,15.8;LB
127PU1.5,13.5;LBX#;
128PU1.5,12.4;LBX#;
129PU9.6,10.7;LB/ES/
130PU17.6,10.7;LB
131PU1.5,7.0;LB
132PU1.5,3.9;LB
133PU17.9,3.9;LB
134PU1.5,3.2;LB
135PU8.2,3.2;LB
136PU13.4,3.2;LB
137PU17.9,3.2;LB
138PU1,3.9;LB
139DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;
140PU.5,28.8;LBOfficial Supervisor's Report: Please complete information requested below:#;
141PU.4,28.2;FT10,10;RA21,28.6;EA21,28.6;PU.5,28.3;LBSupervisor's Report#;
142PU.5,27.9;LB17. Agency name and address of reporting office (Include city, state, and ZIP code)#;
143PU17,28.2;PD17,27.3;PU17.1,27.9;LBOWCP Agency Code#;
144PU15.7,26.4;PD15.7,27.3;PU15.8,27;LBOSHA Site Code#;PU14.5,26.1;LBZIP Code#;
145PU.5,26.1;LB18. Employee's duty station (Street address and ZIP code)#;
146PU.5,25.3;LB19. Employee's retirement coverage#;
147PU7.2,25.3;EA7.4,25.1;PU7.8,25.1;LBCSRS#
148PU9.2,25.3;EA9.4,25.1;PU9.8,25.1;LBFERS#
149PU11.2,25.3;EA11.4,25.1;PU11.8,25.1;LBOther, (Identify)#
150PU.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:#;
151PU4.1,24.2;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#;
152SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.8,23.6;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
153PU7.4,24.2;EA7.6,24.4;PU7.8,24.2;LBa.m.#;PU7.4,23.7;EA7.6,23.9;PU7.8,23.7;LBp.m.#;
154PU8.9,24.7;PD8.9,23.4;PU9,24.4;LB21. Regular#;PU9.6,24;LBwork#;PU9.6,23.6;LBschedule#;
155PU11,23.6;EA11.2,23.8;PU11.4,23.6;LBSun.#;PU12.3,23.6;EA12.5,23.8;PU12.7,23.6;LBMon.#;
156PU13.6,23.6;EA13.8,23.8;PU14,23.6;LBTues.#;PU14.9,23.6;EA15.1,23.8;PU15.3,23.6;LBWed.#;
157PU16.2,23.6;EA16.4,23.8;PU16.6,23.6;LBThurs.#;PU17.7,23.6;EA17.9,23.8;PU18.1,23.6;LBFri.#;
158PU18.8,23.6;EA19,23.8;PU19.2,23.6;LBSat.#;
159PU.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.#;
160PU5.6,23.4;PD5.6,22.4;PU5.7,23.1;LB23. Date#;PU8,23.1;LBMo.#;PU9,23.1;LBDay#;PU10,23.1;LBYr.#;
161PU11,23.4;PD11,22.4;PU11.1,23.1;LB24. Date#;PU13.2,23.1;LBMo.#;PU14.2,23.1;LBDay#;PU15.2,23.1;LBYr.#;
162PU1,22.8;LBof#;PU6.2,22.8;LBnotice#;PU11.6,22.8;LBstopped#;
163PU1,22.5;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;
164PU6.2,22.5;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;
165PU9.7,22.5;PD9.7,22.7;PU10.5,22.5;PD10.5,22.7;
166PU11.6,22.5;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;
167PU14.8,22.5;PD14.8,22.7;PU15.7,22.5;PD15.7,22.7;
168PU16,22.5;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;
169PU17.8,23;EA18,23.2;PU18.2,23;LBa.m.#;PU17.8,22.5;EA18,22.7;PU18.2,22.5;LBp.m.#;
170PU.5,22.4;PD21,22.4;
171PU.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#;
172PU6.1,21.8;LB45 day#;
173PU8.4,22.1;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#;
174PU13.4,22.1;LBMo.#;PU14.4,22.1;LBDay#;PU15.4,22.1;LBYr.#;
175PU1,21.8;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;
176PU4.2,21.5;PD4.2,21.7;
177PU5.2,21.5;PD5.2,21.7;
178PU6.1,21.5;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;
179PU10.1,21.5;PD10.1,21.7;PU11,21.5;PD11,21.7;
180PU11.9,21.8;LBreturned#;PU11.9,21.5;LBto work#;PU13.2,21.5;PD16,21.5;PU13.2,21.5;PD13.2,21.7;
181PU14.2,21.5;PD14.2,21.7;PU15.2,21.5;PD15.2,21.7;
182PU16,21.5;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;
183PU18.2,21.9;EA18.4,22.1;PU18.6,21.9;LBa.m.#;PU18.2,21.5;EA18.4,21.7;PU18.6,21.5;LBp.m.#;
184PU.5,21.3;PD21,21.3;
185PU.5,21;LB28. Was employee injured in performance of duty?#
186PU7.6,21;EA7.8,21.2;PU8,21;LBYes#;PU9,21;EA9.2,21.2;PU9.4,21;LBNo#;PU10,21;LB(If
187PU.5,19.8;PD21,19.8;PU.5,19.5;LB29. Was injury caused by employee's willful misconduct, intoxication,#;
188LB or intent to injure self or another?#;
189PU15,19.5;EA15.2,19.7;PU15.4,19.5;LBYes#;PU16.2,19.5;LB(If
190Yes,
191PU19.2,19.5;EA19.4,19.7;PU19.6,19.5;LBNo#;
192PU.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;
193PU4.3,18.1;LB31. Name and address of third party (Include city, state, and ZIP code)#;
194PU1,17.7;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#;
195PU2.7,16.9;LB(If
196#;PU2.7,16.5;LBgo to#;PU2.7,16.1;LBitem 32.)#;
197PU.5,15.8;PD21,15.8;PU.5,15.5;LB32. Name and address of physician first providing medical care#;
198LB (Include city, state, ZIP code)#;
199PU14.5,15.8;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.#;
200PU15.1,15.2;LBmedical care#;PU15.1,14.9;LBreceived#;PU14.5,14.6;PD21,14.6;
201PU16.8,14.8;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;
202PU14.6,14.3;LB34. Do medical#;PU15.1,14;LBreports show#;PU15.1,13.7;LBemployee is#;PU15.1,13.4;LBdisabled for work?#;
203PU17.4,14.1;EA17.6,14.3;PU17.8,14.1;LBYes#;PU18.8,14.1;EA19,14.3;PU19.2,14.1;LBNo#;
204PU.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;
205PU.5,12.8;LB35. Does your knowledge of the facts about this injury agree with statements#;
206LB of the employee and/or witness?#;
207PU15.8,12.7;EA16,12.9;PU16.2,12.7;LBYes#;PU17.1,12.7;EA17.3,12.9;PU17.5,12.7;LBNo (If
208PU.5,11.3;PD21,11.3;PU.5,11;LB36. If the employing agency controverts continuation of pay, state the reason in detail.#;
209PU14.3,9.7;PD14.3,11.3;PU14.4,11;LB37. Pay rate#;PU15,10.7;LBwhen employee#;PU15,10.4;LBstopped work#;
210PU15,9.9;LB$#;PU17.9,9.9;LBPer#;
211PU.5,9.3;RA21,9.7;EA21,9.7;
212PU.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#;
213SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9;LB38. A supervisor who knowingly certifies to any false statement,#;
214PU1.1,8.6;LBmay also be subject to appropriate felony criminal prosecution.#;
215PU1.1,7.9;LBI certify that the information given above and that furnished by the employee on the reverse#;
216LB of this form is true to the best of my#;
217PU1.1,7.6;LBknowledge with the following exception:#;
218PU.5,6.8;PD21,6.8;PU.5,6.5;LBName of supervisor (Type or print)#;
219PU.5,6.1;PD21,6.1;PU.5,5.8;LB Signature of supervisor#;PU12.9,5.8;LBDate#;
220PU.5,5.3;PD21,5.3;PU.5,5;LBSupervisor's Title#;PU12.9,5;LBOffice phone#;
221PU.5,4.6;PD21,4.6;PU.5,4.3;LB39. Filing instructions#;
222PU4.7,3.9;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)#;
223PU4.7,4.3;EA4.9,4.5;PU5.1,3.9;LBNo lost time, medical expense incurred or expected: forward this form to OWCP#;
224PU4.7,3.5;EA4.9,3.7;PU5.1,3.5;LBLost time covered by leave, LWOP, or COP: forward this form to OWCP#;
225PU4.7,3.1;EA4.9,3.3;PU5.1,3.1;LBFirst Aid injury#;
226PU.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#;
227PU1,27.4;LB
228PU17.7,27.4;LB
229PU1,26.6;LB
230PU1,25.7;LB
231PU7.2,25.1;LBX#;
232PU9.2,25.1;LBX#
233PU11.2,25.1;LBX#;
234PU1,24.8;LB
235PU3,23.6;LB
236PU4.1,24.2;LBX#;
237PU4.1,23.7;LBX#;
238PU6.3,23.6;LB
239PU7.4,24.2;LBX#;
240PU7.4,23.7;LBX#;
241PU7.6,21;LBX#;
242PU9,21;LBX#;
243PU1,20;LB
244PU15,19.5;LBX#;
245PU19.2,19.5;LBX#;
246PU1,18.6;LB
247PU1,17.3;LBX#;
248PU2.7,17.3;LBX#;
249PU4.3,17.7;LB
250PU4.3,16.8;LB
251PU4.3,15.9;LB
252PU1,15;LB
253PU1,14.1;LB
254PU1,13.3;LB
255PU17.4,14.1;LBX#;
256PU18.8,14.1;LBX#;
257PU15.8,12.7;LBX#;
258PU17.1,12.7;LBX#;
259PU1,12.4;LB
260PU1,12;LB
261PU1,11.6;LB
262PU1,12.3;LBSee Attached#;
26335. Does your knowledge of the facts about this injury agree with statements of the employee and/or witness?
264PU1,10.6;LB
265PU1,10.2;LB
266PU1,9.8;1LB
267PU1,10.5;LBSee Attached#;
26836. If the employing agency controverts continuation of pay, state the reason in detail.
269PU15.2,9.9;LB
270PU1,7.1;LB
271PU1,6.2;LB
272PU1,5.4;LB/ES/
273PU12.9,5.4;LB
274PU1,4.7;LB
275PU4.7,4.3;LBX#;
276PU4.7,3.9;LBX#;
277PU4.7,3.5;LBX#;
278PU4.7,3.1;LBX#;
279DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;FT10,10;PU.5,27.5;RA21,28;EA21,28;
280PU.6,27.6;LBBenefits for Employees under the Federal Employees' Compensation Act (FECA)#;
281PU.5,27;LBThe FECA, which is administered by the Office of Workers'#;
282PU.5,26.7;LBCompensation Programs (OWCP), provides the following#;
283PU.5,26.4;LBbenefits for job-related traumatic injuries:#;
284PU.5,25.5;LB(1) Continuation of pay for disability resulting from traumatic,#;
285PU1,25.2;LBjob-related injury, not to exceed 45 calendar days. (To be#;
286PU1,24.9;LBeligible for continuation of pay, the employee, or someone#;
287PU1,24.6;LBacting on his/her behalf, must file Form CA-1 within 30 days#;
288PU1,24.3;LBfollowing the injury and provide medical evidence in support#;
289PU1,24;LBof disability within 10 days of submission of the CA-1. Where#;
290PU1,23.7;LBthe employing agency continues the employee's pay, the pay#;
291PU1,23.4;LBmust not be interrupted unless one of the provision's outlined#;
292PU1,23.1;LBin 20 CFR 10.222 apply.#;
293PU.5,22.6;LB(2) Payment of compensation for wage loss after the expiration#;
294PU1,22.3;LBof COP, if disability extends beyond such point, or if COP is not#;
295PU1,22.0;LBpayable. If disability continues after COP expires, Form CA-7,#;
296PU1,21.7;LBwith supporting medical evidence, must be filed with OWCP.#;
297PU1,21.4;LBto avoid interruption of income, the form should be filed on the#;
298PU1,21.1;LB40th day of the COP period.#;
299PU.5,20.6;LB(3) Payment of compensation for permanent impairment of#;
300PU1,20.3;LBcertain organs, members, or functions of the body (such as#;
301PU1,20.0;LBloss or loss of use of an arm or kidney, loss of vision, etc.),#;
302PU1,19.7;LBor for serious disfigurement of the head, face, or neck.#;
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