| [604] | 1 | English French Notes Complete/Exclude
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| 2 | PU10.9,25.5;LB(4) Vocational rehabilitation and related services where#;
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| 3 | PU11.4,25.2;LBdirected by OWCP.#;
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| 4 | PU10.9,24.1;LB(5) All necessary medical care from qualified medical providers.#;
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| 5 | PU11.4,23.8;LBThe injured employee may choose the physician who provides#;
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| 6 | PU11.4,23.5;LBinitial medical care. Generally, 25 miles from the place of#;
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| 7 | PU11.4,23.2;LBinjury, place of employment, or employee's home is a reasonable#;
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| 8 | PU11.4,22.9;LBdistance to travel for medical care.#;
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| 9 | PU11.4,22.2;LBAn employee may use sick or annual leave rather than LWOP#;
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| 10 | PU11.4,21.9;LBwhile disabled. The employee may repurchase leave used#;
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| 11 | PU11.4,21.6;LBfor approved periods. Form CA-7b, available from the#;
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| 12 | PU11.4,21.3;LBpersonnel office, should be studied BEFORE a decision#;
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| 13 | PU11.4,21.0;LBis made to use leave.#;
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| 14 | PU11.4,20.3;LBFor additional information, review the regulations governing#;
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| 15 | PU11.4,20.0;LBthe administration of the FECA (Code of Federal Regulations,#;
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| 16 | PU11.4,19.7;LBChapter 20, Part 10) or pamphlet CA-810.#;
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| 17 | 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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| 18 | 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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| 19 | 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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| 20 | 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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| 21 | 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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| 22 | 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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| 23 | 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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| 24 | 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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| 25 | 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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| 26 | 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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| 27 | 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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| 28 | 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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| 29 | 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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| 30 | 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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| 31 | 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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| 32 | 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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| 33 | 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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| 34 | 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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| 35 | 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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| 36 | PU.5,9.0;LBprocessing and adjudication of the claim you filed under the FECA. #;
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| 37 | 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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| 38 | PU.5,7.5;LBThis acknowledges receipt of notice of injury sustained by:#;
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| 39 | PU.5,7.2;LB(Name of injured employee)#;
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| 40 | PU.5,6.3;PD21,6.3;PU.5,6;LBWhich occurred on (Mo., Day, Yr.)#;
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| 41 | PU.5,5.5;PD21,5.5:PU.5,5.2;LBAt (Location)#;
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| 42 | PU.5,4.2;PD21,4.2;PU.5,3.9;LBSignature of Official Superior#;
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| 43 | PU9.4,3.9;LBTitle#;PU16.3,3.9;LBDate (Mo., Day, Yr.)#;
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| 44 | DT@,1;
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| 45 | SD1,277,2,1,4,12,5,0,6,0,7,16901;PU.4,28.7;LBNotice of Occupational Disease@;
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| 46 | PU.4,28.2;LBand Claim for Compensation@;
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| 47 | SD1,277,2,1,4,12,5,0,6,1,7,23;PU10.5,28.7;LBU.S. Department of Labor@;
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| 48 | SD1,277,2,1,4,10,5,0,6,0,7,16901;PU10.5,28.2;LBEmployment Standards Administration@;
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| 49 | PU10.5,27.9;LBOffice of Workers' Compensation Programs@;
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| 50 | PU.4,27.7;PD21,27.7;
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| 51 | SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,27.3;LBEmployee: Please complete all boxes 1 - 18 below. Do not complete shaded areas.@;
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| 52 | PU.4,26.9;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.@;
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| 53 | PU.4,26.7;PD21,26.7;PU.4,26.3;FT10,10;RA21,26.7;PU.4,26.4;LBEmployee Data@;PU.4,26.3;PD21,26.3;
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| 54 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.4,26;LB1. Name of employee (Last, First, Middle)@;
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| 55 | PU15.7,26.3;PD15.7,25.4;PU15.8,26;LB2. Social Security Number@;PU.4,25.4;PD21,25.4;
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| 56 | PU.4,25.1;LB3. Date of birth@;PU3,25.1;LBMo.@;PU3.9,25.1;LBDay@;PU4.9,25.1;LBYr.@;
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| 57 | PU6.3,24.6;PD6.3,25.4;PU6.4,25.1;LB4. Sex@;PU8,25.4;PD8,24.6;PU8.1,25.1;LB5. Home telephone@;
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| 58 | PU12.4,25.4;PD12.4,24.6;PU12.5,25.1;LB6. Grade as of date@;
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| 59 | PU2.9,24.7;PD5.4,24.7;PU2.9,24.7;PD2.9,24.9;PU3.7,24.7;PD3.7,24.9;PU4.7,24.7;PD4.7,24.9;PU5.4,24.7;PD5.4,24.9;
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| 60 | PU13,24.7;LBof last exposure@;PU15.6,24.7;LBLevel@;PU17.9,24.7;LBStep@;
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| 61 | PU.4,24.6;PD21,24.6;PU.4,24.3;LB7. Employee's home mailing address (Include city, state, and zip code)@;
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| 62 | PU15.9,24.3;LB8. Dependents@;PU16.2,23.8;EA16.4,24;PU16.6,23.8;LBWife, Husband@;
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| 63 | PU16.2,23.4,EA16.4,23.6;PU16.6,23.4;LBChildren under 18 years@;
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| 64 | PU16.2,23;EA16.4,23.2;PU16.6,23;LBOther@;
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| 65 | SD1,277,2,1,4,9,5,0,6,1,7,23;PU15.8,21.7;LBa. Occupation code@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 66 | PU.4,22.5;PD21,22.5;PU15.8,24.6;PD15.8,22.5;
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| 67 | PU.4,22;PD21,22;PU.4,22.1;SD1,277,2,1,4,9,5,0,6,1,7,23;LBClaim Information@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 68 | PU.4,22;RA21,22.5;PU.4,21.7;LB9. Employee's occupation@;PU.4,20.7;PD21,20.7;
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| 69 | PU.4,20.4;LB10. Location (address) where you worked when disease or illness occurred (Include city, state, and zip code)@;
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| 70 | PU15.8,20.4;LB11. Date you first became@;PU16.3,20.1;LBaware of disease@;
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| 71 | PU16.3,19.7;LBor illness@;PU16.3,19.3;LBMo.@;PU17.3,19.3;LBDay@;PU18.3,19.3;LBYr.@;
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| 72 | PU16.3,18.7;PD18.7,18.7;PU16.3,18.7;PD16.3,18.9;PU17.1,18.7;PD17.1,18.9;PU18,18.7;PD18,18.9;PU18.7,18.7;PD18.7,18.9;
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| 73 | PU.4,18.6;PD15.7,18.6;EA21,22;PU15.7,20.7;RA21,22;
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| 74 | PU.4,18.3;LB12. Date you first realized@;PU.9,18;LBthe disease or illness@;PU4.8,18;LBMo.@;PU5.7,18;LBDay@;
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| 75 | PU6.7,18;LBYr.@;PU.9,17.7;LBwas caused or aggravated@;PU.9,17.4;LBby your employment@;
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| 76 | PU4.7,17.4;PD7.3,17.4;PU4.7,17.4;PD4.7,17.6;PU5.6,17.4;PD5.6,17.6;PU6.4,17.4;PD6.4,17.6;PU7.3,17.4;PD7.3,17.6;
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| 77 | PU7.4,18.6;PD7.4,17.3;PD.5,17.3;PU7.5,18.3;LB13. Explain the relationship@;
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| 78 | LB to your employment, and why you came to this realization@;
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| 79 | PU.4,14.5;PD15.7,14.5;PU15.7,13.8;EA21,14.5;PU15.7,12.8;EA17.9,13.8;RA21,14.5;PU17.9,12.8;EA21,13.8;
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| 80 | PU.4,14.2;LB14. Nature of disease or illness@;PU15.8,14.2;SD1,277,2,1,4,9,5,0,6,1,7,23;LBOWCP Use - NOI Code@;
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| 81 | PU15.8,13.5;LBb. Type code@;PU18,13.5;LBc. Source code@;PU.4,12.8;PD15.7,12.8;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 82 | PU.4,12.5;LB15. If this notice and claim was not filed with the employing agency within 30 days after date shown@;
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| 83 | LB above in item #12, explain the reason for the delay.@;PU.4,11;PD21,11;
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| 84 | PU.4,10.7;LB16. If the statement requested in item 1 of the attached instructions is not submitted@;
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| 85 | LB with this form, explain reason for delay.@;
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| 86 | PU.4,9.3;PD21,9.3;PU.4,9;LB17. If the medical reports requested in the item 2 of attached instructions@;
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| 87 | LB are not submitted with this form, explain reason for delay.@;
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| 88 | PU.4,7.6;PD21,7.6;PU.4,7.1;PD21,7.1;
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| 89 | PU.4,7.1;RA21,7.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,7.2;LBEmployee Signature@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 90 | PU.4,6.7;LB18. I certify, under penalty of law, that the disease or illness described above@;
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| 91 | LB was the result of my employment with the United States@;
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| 92 | PU.9,6.4;LBGovernment, and that it was not caused by my willful misconduct, intent to injure@;
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| 93 | LB myself or another person, nor by my intoxication.@;
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| 94 | PU.9,6.1;LBI hereby claim medical treatment, if needed, and other benefits provided@;
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| 95 | LB by the Federal Employees' Compensation Act.@;
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| 96 | PU.9,5.5;LBI hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any@;
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| 97 | PU.9,5.2;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative).@;
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| 98 | PU.9,4.9;LBThis authorization also permits any official representative of the Office to examine and to copy any records concerning me.@;
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| 99 | SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,4.4;LBSignature of employee or person acting on his/her behalf@;PU8.8,4.4;PD21,4.4;
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| 100 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU16.3,4.5;LBDate@;
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| 101 | PU.4,3.9;LBHave your supervisor complete the receipt attached to this form and return it to you for your records.@;
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| 102 | PU.4,3.4;LBAny person who knowingly makes any false statement, misrepresentation,@;
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| 103 | LB concealment of fact, or any other act of fraud to obtain compensation@;
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| 104 | PU.4,3.1;LBas provided by the FECA or who knowingly accepts compensation to which@;
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| 105 | LB that person is not entitled, is subject to civil or administrative remedies@;
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| 106 | PU.4,2.8;LBas well as felony criminal prosecution and may, under appropriate provisions, be punished by a fine or imprisonment, or both.@;
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| 107 | PU.4,2.6;PD21,2.6;
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| 108 | PU18.5,2.2;LBForm CA-2@;PU18.5,1.8;LBRev. Jan. 1997@;
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| 109 | PU0.8,25.5;LB
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| 110 | PU15.9,25.5;LB
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| 111 | PU6.5,24.7;LB
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| 112 | PU8.7,24.7;LB
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| 113 | PU16.6,24.7;LB
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| 114 | PU0.8,23.5;LB
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| 115 | PU12.8,22.7;LB
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| 116 | PU16.2,23.8;LBX@;
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| 117 | PU16.2,23.4;LBX@;
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| 118 | PU16.2,23;LBX@;
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| 119 | PU16.2,23.8;LBX@;PU16.2,23.4;LBX@;
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| 120 | PU16.2,23.8;LBX@;PU16.2,23;LBX@;
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| 121 | PU16.2,23.4;LBX@;PU16.2,23;LBX@;
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| 122 | PU16.2,23.8;LBX@;PU16.2,23.4;LBX@;PU16.2,23;LBX@;
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| 123 | PU0.8,20.9;LB
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| 124 | PU16.2,21.1;LB
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| 125 | PU0.8,19.7;LB
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| 126 | PU0.8,18.8;LB
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| 127 | PU0.8,16.9;LB
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| 128 | PU0.8,16.5;LB
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| 129 | PU0.8,16.1;LB
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| 130 | PU0.8,15.7;LB
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| 131 | PU0.8,15.3;LB
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| 132 | PU0.8,14.9;LB
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| 133 | PU7.9,17.6;LBSee Attached@;
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| 134 | 13. Explain the relationship to your employment, and why you came to this realization.
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| 135 | PU1,13.7;LB
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| 136 | PU1,12.9;LB
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| 137 | PU1,13.6;LBSee Attached@;
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| 138 | 14. Nature of disease or illness.
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| 139 | PU16.2,13.9;LB
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| 140 | PU16.2,13.0;LB
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| 141 | PU18.0,13.0;LB
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| 142 | PU1,11.2;LB
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| 143 | PU1,12;LBSee Attached@;
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| 144 | 15. If this notice and claim was not filed with the employing agency within
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| 145 | PU1,10.3;LB
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| 146 | PU1,9.9;LB
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| 147 | PU1,9.5;LB
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| 148 | PU1,10.3LBSee Attached@;
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| 149 | 16. If the statement requested in item 1 of the attached instructions is not
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| 150 | PU1,8.6;LB
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| 151 | PU1,8.2;LB
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| 152 | PU1,7.8;LB
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| 153 | PU1,8.6LBSee Attached@;
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| 154 | 17. If the medical reports requested in item 2 of attached instructions
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| 155 | PU9.5,4.5;LB/ES/
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| 156 | PU17.3,4.5;LB
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| 157 | PU4.2,18.8;PD4.2,19;PU5.1,18.8;PD5.1,19;PU5.9,18.8;PD5.9,19;
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| 158 | PU3.3,17.5;PD3.3,17.7;PU4.2,17.5;PD4.2,17.7;
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| 159 | PU.5,13.7;PD21,13.7;PU.5,13.4;LB32. Employee's Retirement Coverage@;
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| 160 | PU7.2,13.4;EA7.4,13.2;PU7.8,13.2;LBCSRS@;
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| 161 | PU9.2,13.4;EA9.4,13.2;PU9.8,13.2;LBFERS@;
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| 162 | PU11.2,13.4;EA11.4,13.2;PU11.8,13.2;LBOther, (Identify)@;
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| 163 | PU.5,12.3;LB33. 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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| 164 | PU3.7,12.3;LB34. Name and address of third party (Include city, state, and zip code)@;
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| 165 | PU18.5,2.5;LBForm CA-2@;PU18.5,2.1;LBRev. Jan. 1997@;
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| 166 | PU0.8,27.4;LB
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| 167 | PU0.8,26.5;LB
|
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| 168 | PU0.8,25.7;LB
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| 169 | PU0.8,24.8;LB
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| 170 | PU17.5,24.8;LB
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| 171 | PU3,23.8;LB
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| 172 | PU4.1,24.2;LBX@;
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| 173 | PU4.1,23.8;LBX@;
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| 174 | PU6.3,23.8;LB
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| 175 | PU7.4,24.2;LBX@;
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| 176 | PU7.4,23.8;LBX@;
|
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| 177 | PU0.8,22.7;LB
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| 178 | PU0.8,21.9;LB
|
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| 179 | PU0.8,21.1;LB
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| 180 | PU17.5,21.7;LBX@;
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| 181 | PU18.9,21.7LBX@;
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| 182 | PU0.8,16.3;LB
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| 183 | PU0.8,15.9;LB
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| 184 | PU0.8,15.5;LB
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| 185 | PU0.8,15.1;LB
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| 186 | PU0.8,14.7;LB
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| 187 | PU0.8,14.3;LB
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| 188 | PU0.8,13.9;LB
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| 189 | PU.8,16.2,12.3;LBSee Attached@;
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| 190 | 31. If employee has returned to work and work assignment has changed,
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| 191 | PU7.2,13.2;LBX@;
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| 192 | PU9.2,13.2;LBX@
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| 193 | PU11.2,13.2;LBX@;
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| 194 | PU1,12.7;LB
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| 195 | PU0.9,11.5;LBX@;
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| 196 | PU2.3,11.5;LBX@;
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| 197 | PU3.8,11.8;LB
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| 198 | PU3.8,11;LB
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| 199 | PU3.8,10.2;LB
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| 200 | PU1,7.5;LB
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| 201 | PU0.8,5.5;LB
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| 202 | PU0.8,4.7;LB/ES/
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| 203 | PU12.5,4.7;LB
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| 204 | PU0.8,3.8;LB
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| 205 | 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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| 206 | PU.5,28.3;LBDisability Benefits for Employees under the Federal Employees' Compensation Act (FECA)@;
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| 207 | PU.5,28.2;FT10,10;RA21,28.6;PU.5,28.2;PD21,28.2;
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| 208 | PU.5,27.6;LBThe FECA, which is administered by the Office of Workers'@;
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| 209 | PU10.9,27.6;LBThe first three days in a non-pay status are waiting days, and@;
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| 210 | PU.5,27.3;LBCompensation Programs (OWCP), provides the following@;
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| 211 | PU10.9,27.3;LBno compensation is paid for these days unless the period of@;
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| 212 | PU.5,27;LBgeneral benefits for employment-related occupational disease@;
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| 213 | PU10.9,27;LBdisability exceeds 14 calendar days, or the employee has@;
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| 214 | PU.5,26.7;LBor illness:@;
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| 215 | PU10.9,26.7;LBsuffered a permanent disability. Compensation for total disa-@;
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| 216 | PU10.9,26.4;LBbility is generally paid at the rate of 2/3 of an employee's@;
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| 217 | PU10.9,26.1;LBsalary if there are no dependents, or 3/4 of salary if there are@;
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| 218 | PU10.9,25.8;LBone or more dependents.@;
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| 219 | PU.5,26;LB(1) Full medical care from either Federal medical officers and@;
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| 220 | PU1,25.7;LBhospitals, or private hospitals or physicians of the@;
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| 221 | PU1,25.4;LBemployee's choice.@;
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| 222 | PU.5,24.6;LB(2) Payment of compensation for total or partial wage loss.@;
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| 223 | PU.5,23.9;LB(3) Payment of compensation for permanent impairment of@;
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| 224 | PU1,23.6;LBcertain organs, members, or functions of the body (such as@;
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| 225 | PU1,23.3;LBloss or loss of use of an arm or kidney, loss of vision, etc.),@;
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| 226 | PU1,23;LBor for serious disfigurement of the head, face, or neck.@;
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| 227 | PU.5,22.3;LB(4) Vocational rehabilitation and related services where@;
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| 228 | PU1,22;LBnecessary.@;
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| 229 | PU10.9,25.2;LBAn employee may use sick or annual leave rather than LWOP@;
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| 230 | PU10.9,24.9;LBwhile disabled. The employee may repurchase leave used@;
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| 231 | PU10.9,24.6;LBfor approved periods. Form CA-7b, available from the@;
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| 232 | PU10.9,24.3;LBpersonnel office, should be studied BEFORE a decision is@;
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| 233 | PU10.9,24.0;LBmade to use leave.@;
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| 234 | PU10.9,23.4;LBIf an employee is in doubt about compensation benefits, the@;
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| 235 | PU10.9,23.1;LBOWCP District Office servicing the employing agency should@;
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| 236 | PU10.9,22.8;LBbe contacted. (Obtain the address from your employing@;
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| 237 | PU10.9,22.5;LBagency.)@;
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| 238 | PU10.9,21.9;LBFor additional information, review the regulations governing the@;
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| 239 | PU10.9,21.6;LBadministration of the FECA (Code of Federal Regulations, Title@;
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| 240 | PU10.9,21.3;LB20, Chapter 1) or Chapter 810 of the Office of Personnel@;
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| 241 | PU10.9,21.0;LBManagement's Federal Personnel Manual.@;
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| 242 | 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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| 243 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,19.7;RA21,20.2;
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| 244 | 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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| 245 | 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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|---|
| 246 | 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)@;
|
|---|
| 247 | 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@;
|
|---|
| 248 | PU.5,17.0;LBverified through computer matches or other appropriate means. (3) Information may be given to the Federal Agency which employed the@;
|
|---|
| 249 | 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@;
|
|---|
| 250 | PU.5,16.0;LBconsider issues relating to retention, rehire, or relevant matters. (4) Information may also be given to other Federal agencies, other@;
|
|---|
| 251 | 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. @;
|
|---|
| 252 | 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@;
|
|---|
| 253 | 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@;
|
|---|
| 254 | 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@;
|
|---|
| 255 | PU.5,13.5;LBdetermine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to@;
|
|---|
| 256 | 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)@;
|
|---|
| 257 | 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@;
|
|---|
| 258 | 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@;
|
|---|
| 259 | 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@;
|
|---|
| 260 | PU.5,11.0;LBof the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.@;
|
|---|
| 261 | 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@;
|
|---|
| 262 | PU.5,10.0;LBprocessing and adjudication of the claim you filed under the FECA. @;
|
|---|
| 263 | SD1,277,2,1,4,10,5,0,6,1,7,23;PU.5,9.3;LBReceipt of Notice of Occupational Disease or Illness@;
|
|---|
| 264 | 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;
|
|---|
| 265 | PU.5,9.2;RA21,9.7;PU.5,8.7;LBThis acknowledges receipt of notice of disease or illness sustained by:@;
|
|---|
| 266 | PU.5,8.4;LB(Name of injured employee)@;
|
|---|
| 267 | PU.5,7.7;PD21,7.7;PU.5,7.4;LBI was first notified about this condition on (Mo., Day, Yr.)@;
|
|---|
| 268 | PU.5,6.9;PD21,6.9:PU.5,6.6;LBAt (Location)@;
|
|---|
| 269 | PU.5,5.5;PD21,5.5;PU.5,5.2;LBSignature of Official Superior@;
|
|---|
| 270 | PU9.4,5.2;LBTitle@;PU16.3,5.2;LBDate (Mo., Day, Yr.)@;
|
|---|
| 271 | 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.@;
|
|---|
| 272 | DT#,1;SD1,277,2,1,4,10,5,0,6,2,7,23;PU.5,28.3;LBInstructions for Completing Form CA-1#;PU.5,28.1;PD21,28.1;
|
|---|
| 273 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.6;LBComplete all items on your section of the form. If additional space is required to #;
|
|---|
| 274 | LBexplain or clarify any point, attach a supplemental#;
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|---|
| 275 | PU.5,27.3;LBstatement to the form. Some of the items on the form which may require #;
|
|---|
| 276 | LBfurther clarification are explained below.#
|
|---|
| 277 | FT10,10;PU.5,26.5;RA21,27;EA21,27;PU.6,26.6;LBEmployee (Or person acting on the employees' behalf)#;
|
|---|
| 278 | PU.5,26.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB13) Cause of Injury#;
|
|---|
| 279 | PU11,26.1;LB15) Election of COP/Leave#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
|
|---|
| 280 | PU.5,25.7;LBDescribe in detail how and why the injury occurred. Give#;
|
|---|
| 281 | PU11,25.7;LBIf you are disabled for work as a result of this injury and filed#;
|
|---|
| 282 | PU11,25.4;LBCA-1 within thirty days of the injury, you may be entitled to receive#;
|
|---|
| 283 | PU.5,25.4;LBappropriate details (e.g.: if you fell, how far did you fall and in#;
|
|---|
| 284 | PU11,25.1;LBcontinuation of pay (COP) from your employing agency. COP is#;
|
|---|
| 285 | PU11,24.8;LBpaid for up to 45 calendar days of disability, and is not charged#;
|
|---|
| 286 | PU11,24.5;LBagainst sick or annual leave. If you elect sick or annual leave#;
|
|---|
| 287 | PU11,24.2;LByou may not claim compensation to repurchase leave used#;
|
|---|
| 288 | PU11,23.9;LBduring the 45 days of COP entitlement.#;
|
|---|
| 289 | PU.5,25.1;LBwhat position did you land?)#;
|
|---|
| 290 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,24.5;LB14) Nature of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
|
|---|
| 291 | PU.5,24.1;LBGive a complete description of the condition(s) resulting from#;
|
|---|
| 292 | PU.5,23.8;LByour injury. Specify the right or left side if applicable (e.g.,#;
|
|---|
| 293 | PU.5,23.5;LBfractured left leg: cut on right index finger).#;
|
|---|
| 294 | PU.5,22.6;RA21,23.1;EA21,23.1;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.6,22.7;LBSupervisor#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
|
|---|
| 295 | PU.5,22.1;LBAt the time the form is received, complete the receipt of notice of#;
|
|---|
| 296 | PU11,22.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB33) First date medical care received#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
|
|---|
| 297 | PU.5,21.8;LBinjury and give it to the employee. In addition to completing#;
|
|---|
| 298 | PU.5,21.5;LBitems 17 through 39, the supervisor is responsible for obtaining#;
|
|---|
| 299 | PU11,21.6;LBThe date of the first visit to the physician listed in item 31.#
|
|---|
| 300 | PU.5,21.2;LBthe witness statement in item 16 and for filling in the proper codes#;
|
|---|
| 301 | PU.5,20.9;LBin shaded boxes a, b, and c on the front of the form. If medical#;
|
|---|
| 302 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20.8;LB36) If the emloying agency controverts continuation#;
|
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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