| [604] | 1 | English French Notes Complete/Exclude
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| 2 | PU11.5,20.4;LBof pay, state, the reason in detail#;
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| 3 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,20.6;LBexpense or lost time is incurred or expected, the completed form#;
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| 4 | PU.5,20.3;LBshould be sent to OWCP within 10 working days after it is received.#;
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| 5 | PU.5,19.5;LBThe supervisor should also submit any other information or#;
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| 6 | PU.5,19.2;LBevidence pertinent to the merits of this claim.#;
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| 7 | PU11,19.9;LBCOP may be controverted (disputed) for any reason; however,#;
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| 8 | PU11,19.6;LBthe employing agency may refuse to pay COP only if the#;
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| 9 | PU11,19.3;LBcontroversion is based upon one of the nine reasons given#;
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| 10 | PU11,19;LBbelow:#
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| 11 | PU.5,18.5;LBIf the employing agency controverts COP, the employee should#;
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| 12 | PU11,18.4;LBa) The disability was not caused by a traumatic injury.#;
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| 13 | PU.5,18.2;LBbe notified and the reason for controversion explained to him or#;
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| 14 | PU.5,17.9;LBher.#;
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| 15 | PU11,17.7;LBb) The employee is a volunteer working without pay or for#;
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| 16 | PU11.5,17.4;LBnominal pay, or a member of the office staff of a former#;
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| 17 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,17.2;LB17) Agency name and address of reporting office#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 18 | PU11.5,17.1;LBPresident;#;
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| 19 | PU.5,16.7;LBThe name and address of the office to which correspondence#;
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| 20 | PU11,16.6;LBc) The employee is not a citizen or a resident of the United#;
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| 21 | PU.5,16.4;LBfrom OWCP should be sent (if applicable, the address of the#;
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| 22 | PU11.5,16.3;LBStates or Canada;#;
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| 23 | PU.5,16.1;LBpersonnel or compensation office).#;
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| 24 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,15.5;LB18) Duty station street address and zip code#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 25 | PU11,15.6;LBd) The injury occurred off the employing agency's premises and#;
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| 26 | PU11.5,15.3;LBthe employee was not involved in official
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| 27 | off premise
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| 28 | PU.5,15;LBThe address and zip code of the establishment where the#;
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| 29 | PU.5,14.7;LBemployee actually works.#;
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| 30 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,14.1;LB19) Employers Retirement Coverage.#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 31 | PU.5,13.7;LBIndicate which retirement system the employee is covered under.#;
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| 32 | PU11,14.5;LBe) The injury was proximately caused by the employee's willful#;
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| 33 | PU11.5,14.2;LBmisconduct, intent to bring about injury or death to self or#;
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| 34 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LB30) Was injury caused by third party?#;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 35 | PU11.5,13.9;LBanother person, or intoxication;#;
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| 36 | PU.5,12.4;LBA third party is an individual or organization (other than the#;
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| 37 | PU.5,12.1;LBinjured employee or the Federal government) who is liable for#;
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| 38 | PU11,13.1;LBf) The injury was not reported on Form CA-1 within 30 days#;
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| 39 | PU.5,11.8;LBthe injury. For instance, the driver of a vehicle causing an#;
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| 40 | PU11.5,12.8;LBfollowing the injury;#;
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| 41 | PU.5,11.5;LBaccident in which an employee is injured, the owner of a#;
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| 42 | PU.5,11.2;LBbuilding where unsafe conditions cause an employee to fall, and#;
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| 43 | PU11,12.1;LBg) Work stoppage first occurred 45 days or more following#;
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| 44 | PU.5,10.9;LBa manufacturer whose defective product causes an employee's#;
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| 45 | PU11.5,11.8;LBthe injury;#;
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| 46 | PU.5,10.6;LBinjury, could all be considered third parties to the injury.#;
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| 47 | PU11,11.1;LBh) The employee initially reported the injury after his or her#;
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| 48 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,9.8;LB32) Name and address of physician first providing#;PU.5,9.4;LBmedical care#;
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| 49 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11.5,10.8;LBemployment was terminated; or#;
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| 50 | PU11,10.1;LBi) The employee is enrolled in the Civil Air Patrol, Peace Corps,#;
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| 51 | PU.5,8.9;LBThe name and address of the physician who first provided#;
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| 52 | PU11.5,9.8;LBYouth Conservation Corps, Work Study Programs, or other#;
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| 53 | PU.5,8.6;LBmedical care for this injury. If initial care was given by a nurse#;
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| 54 | PU11.5,9.5;LBsimilar groups.#;
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| 55 | PU.5,8.3;LBor other health professional (not a physician) in the employing#;
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| 56 | PU.5,8;LBagency's health unit or clinic, indicate this on a separate sheet#;
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| 57 | PU.5,7.7;LBof paper.#;
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| 58 | PU.5,6.6;EA21,7.1;RA21,7.1;PU.6,6.7;SD1,277,2,1,4,9,5,0,6,2,7,23;
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| 59 | PU.6,6.7;LBEmploying Agency - Required Codes#;
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| 60 | PU.5,6.2;LBBox a (Occupation Code), Box b (Type Code),#;
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| 61 | PU.5,5.8;LBBox c (Source Code), OSHA Site Code#;PU11,6.2;LBOWCP Agency Code#;
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| 62 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11,5.6;LBThis is a four-digit (or four digit plus two letter) code used by#;
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| 63 | PU.5,5.3;LBThe Occupational Safety and Health Administration (OSHA)#;
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| 64 | PU11,5.3;LBOWCP to identify the employing agency. The proper code may#;
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| 65 | PU.5,5;LBrequires all employing agencies to complete these items when#;
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| 66 | PU11,5;LBbe obtained from your personnel or compensation office, or by#;
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| 67 | PU.5,4.7;LBreporting an injury. The proper codes may be found in OSHA#;
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| 68 | PU11,4.7;LBcontacting OWCP.#;
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| 69 | PU.5,4.4;LBBooklet 2014, Recordkeeping and Reporting Guidelines.#;
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| 70 | PU.5,4;PD21,4;PU18,3.5;LBForm CA-1#;PU18,3;LBRev. Apr. 1999#;
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| 71 | IN;SP1;IP;PW.2;SC0,22,0,29,1;
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| 72 | DT@,1;SD1,277,2,1,4,10,5,0,6,2,7,23;
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| 73 | PU.5,28.3;LBInstructions for Completing Form CA-2@;
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| 74 | PU.5,28.1;PD22,28.1;
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| 75 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.7;LBComplete all items on your section of the form. If additional space is required @;
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| 76 | LBto explain or clarify any point, attach a supplemental@;
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| 77 | PU0.5,27.4;LBstatement to the form. In addition to the information requested on the form, both the employee @;
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| 78 | LBand the supervisor are required to @;
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| 79 | PU0.5,27.1;LBsubmit additional evidence as decribed below. If this evidence is not submitted @;
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| 80 | LBalong with the form, the responsible party should@;
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| 81 | PU0.5,26.8;LBexplain the reason for the delay and state when the additional evidence will be submitted.@;
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| 82 | PU.5,26.6;PD22,26.6;PU.5,26.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmployee@;
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| 83 | LB (or person acting on the employee's behalf)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 84 | PU.5,26.1;PD22,26.1;PU.5,26.1;FT10,10;RA22,26.6;
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| 85 | PU0.5,25.7;LBComplete items 1 through 18 and submit the form to the employee's supervisor @;
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| 86 | LBalong with the statement and medical reports described@;
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| 87 | PU0.5,25.4;LBbelow. Be sure to obtain the Receipt of Notice of Disease or Illness completed @;
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| 88 | LBby the supervisor at the time the form is submitted.@;
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| 89 | SD1,277,2,1,4,9,5,0,6,2,7,23;PU0.5,25;LB1) Employee's statement@;
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| 90 | PU11,25;LB2) Medical report@;
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| 91 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU0.5,24.7;LBIn a separate narrative statement attached to the form the@;
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| 92 | PU0.5,24.4;LBemployee must submit the following information:@;
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| 93 | PU1,24;LBa) A detailed history of the disease or illness from the date it@;
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| 94 | PU1.3,23.7;LBstarted.@;
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| 95 | PU1,23.3;LBb) Complete details of the conditions of employment which are@;
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| 96 | PU1.3,23;LBbelieved to be responsible for the disease or illness.@;
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| 97 | PU1,22.6;LBc) A description of specific exposures to substances or stress-@;
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| 98 | PU1.3,22.3;LBful conditions causing the disease or illness, including loca-@;
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| 99 | PU1.3,22;LBtions where exposure or stress occurred, as well as the@;
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| 100 | PU1.3,21.7;LBnumber of hours per day and days per week of such@;
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| 101 | PU1.3,21.4;LBexposure or stress.@;
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| 102 | PU1,21;LBd) Identification of the part of the body affected. (If disability is@;
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| 103 | PU1.3,20.7;LBdue to a heart condition, give complete details of all@;
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| 104 | PU1.3,20.4;LBactivities for one week prior to the attack with particular@;
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| 105 | PU1.3,20.1;LBattention to the final 24 hours of such period.)@;
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| 106 | PU1,19.7;LBe) A statement as to whether the employee ever suffered a@;
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| 107 | PU1.3,19.4;LBsimilar condition. If so, provide full details of onset, history,@;
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| 108 | PU1.3,19.1;LBand medical care received, along with names and addres-@;
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| 109 | PU1.3,18.8;LBses of physicians rendering treatment.@;
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| 110 | PU11.5,24.6;LBa) Dates of examination or treatment.@;
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| 111 | PU11.5,24.2;LBb) History given to the physician by the employee.@;
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| 112 | PU11.5,23.8;LBc) Detailed description of the physician's findings.@;
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| 113 | PU11.5,23.4;LBd) Results of x-rays, laboratory tests, etc.@;
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| 114 | PU11.5,23;LBe) Diagnosis.@;PU11.5,22.6;LBf) Clinical course of treatment.@;
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| 115 | PU11.5,22.2;LBg) Physician's opinion as to whether the disease or illness@;
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| 116 | PU11.8,21.9;LBwas caused or aggravated by the employment, along with@;
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| 117 | PU11.8,21.6;LBan explanation of the basis for this opinion. (Medical@;
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| 118 | PU11.8,21.3;LBreports that do not explain the basis for the physician's@;
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| 119 | PU11.8,21;LBopinion are given very little weight in adjudicating the@;
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| 120 | PU11.8,20.7;LBclaim.)@;SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20;LB3) Wage loss@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 121 | PU11.5,19.6;LBIf you have lost wages or used leave for this illness, Form@;PU11.5,19.3;LBCA-7 should also be submitted.@;
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| 122 | PU.5,18.6;PD22,18.6;
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| 123 | PU.5,18.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBSupervisor@;
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| 124 | LB (Or appropriate official in the employing agency)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 125 | PU.5,18.1;PD22,18.1;PU.5,18.1;RA22,18.6;
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| 126 | PU.5,17.7;LBAt the time the form is received, complete the Receipt of Notice of Disease or Illness and give @;
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| 127 | LBit to the employee. In addition to completing@;
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| 128 | PU.5,17.4;LBitems 19 through 34, the supervisor is responsible for filling in the proper codes @;
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| 129 | LBin shaded boxes a, b, and c on the front of the form. If@;
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| 130 | PU.5,17.1;LBmedical expense or lost time is incurred or expected, the completed form @;
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| 131 | LBmust be sent to OWCP within ten working days after it is@;
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| 132 | PU.5,16.8;LBreceived. In a separate, narrative statement attached to the form, the supervisor must:@;
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| 133 | PU.5,16.4;LBa) Describe in detail the work performed by the employee. Identify@;
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| 134 | PU11,16.4;LBc) Attach a record of the employee's absence from work caused@;
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| 135 | PU1,16.1;LBfumes, chemicals, or other irritants or situations that the employ-@;
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| 136 | PU11.5,16.1;LBby any similar disease or illness. Have the employee state the@;
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| 137 | PU1,15.8;LBee was exposed to which allegedly caused the condition. State@;PU11.5,15.8;LBreason for each absence.@;
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| 138 | PU1,15.5;LBthe nature, extent, and duration of the exposure, including hours@;
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| 139 | PU11,15.4;LBd) Attach statements from each co-worker who has first-hand@;
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| 140 | PU1,15.2;LBper days and days per week, requested above.@;PU11.5,15.1;LBknowledge about the employee's condition and its cause. (The@;
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| 141 | PU.5,14.8;LBb) Attach copies of all medical reports (including x-ray reports and@;
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| 142 | PU11.5,14.8;LBco-workers should state how such knowledge was obtained.)@;
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| 143 | PU1,14.5;LBlaboratory data) on file for the employee.@;
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| 144 | PU11,14.4;LBe) Review and comment on the accuracy of the employee's state-@;PU11.5,14.1;LBment requested above.@;
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| 145 | PU.5,13.7;LBThe supervisor should also submit any other information or evidence pertinent @;
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| 146 | LBto the merits of this claim.@;
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| 147 | PU.5,13.5;PD22,13.5;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LBItem Explanations@;
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| 148 | LB Some of the items on the form which may require further clarification are explained below.@;
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| 149 | PU.5,13;PD22,13;PU.5,13;RA22,13.5;
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| 150 | PU.5,12.5;LB14. Nature of the disease or illness@;
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| 151 | PU1,12.1;LBGive a complete description of the disease or illness. Specify@;
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| 152 | PU1,11.8;LBthe left or right side if applicable (e.g., rash on left leg; carpal@;
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| 153 | PU1,11.5;LBtunnel syndrome, right wrist).@;
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| 154 | SD1,277,2,1,4,9,5,0,6,2,7,23;
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| 155 | PU.5,10.8;LB19. Agency name and address of reporting office@;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 156 | PU1,10.4;LBThe name and address of the office to which correspondence@;
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| 157 | PU1,10.1;LBfrom OWCP should be sent (If applicable, the address of the@;
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| 158 | PU1,9.8;LBpersonnel or compensation office).@;
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| 159 | PU.5,8.9;LB23. Name and address of physician first providing@;
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| 160 | PU1,8.5;LBmedical care@;
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| 161 | PU1,8.1;LBThe name and address of the physician who first provided@;
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| 162 | PU1,7.8;LBmedical care for this injury. If initial care was given by a@;
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| 163 | PU1,7.5;LBnurse or other health professional (not a physician) in the@;
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| 164 | PU1,7.2;LBemploying agency's health unit or clinic, indicate this on a@;
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| 165 | PU1,6.9;LBseparate sheet of paper.@;
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| 166 | PU11,12.5;LB24. First date medical care received@;
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| 167 | PU11.5,12.2;LBThe date of the first visit to the physician listed in item 23.@;
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| 168 | PU11,10.8;LB32. Employee's Retirement Coverage.@;
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| 169 | PU11.5,10.4;LBIndicate which retirement system the employee is covered@;
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| 170 | PU11.5,10.1;LBunder.@;
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| 171 | PU11,9.2;LB33. Was the injury caused by third party?@;
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| 172 | PU11.5,8.9;LBA third party is an individual or organization (other than the@;
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| 173 | PU11.5,8.6;LBinjured employee or the Federal government) who is liable for@;
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| 174 | PU11.5,8.3;LBthe disease. For instance, manufacturer of a chemical to which@;
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| 175 | PU11.5,8;LBan emoloyee was exposed might be considered a third party if@;
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| 176 | PU11.5,7.7;LBimproper instructions were given by the manufacturer for use of@;
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| 177 | PU11.5,7.4;LBthe chemical.@;
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| 178 | PU.5,6.2;PD22,6.2;PU.5,5.8;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmploying Agency - Required Codes@;
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| 179 | PU.5,5.7;PD22,5.7;PU.5,5.7;RA22,6.2;
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| 180 | PU.5,5.2;LBBox a (Occupation Code), Box b (Type Code), Box c@;
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| 181 | PU.5,4.8;LB(Source Code), OSHA Site Code@;PU11,5.2;LBOWCP Agency Code@;
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| 182 | SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,4.4;LBThe Occupational Safety and Health Administration (OSHA)@;
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| 183 | PU11,4.8;LBThis is a four digit (or four digit two letter) code used by@;
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| 184 | PU11,4.5;LBOWCP to identify the employing agency. The proper code@;
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| 185 | PU11,4.2;LBmay be obtained from your personnel or compensation office,@;
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| 186 | PU.5,4.1;LBrequires all employing agencies to complete these items when@;
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| 187 | PU11,3.9;LBor by contacting OWCP.@;
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| 188 | PU.5,3.8;LBreporting an injury. The proper codes may be found in OSHA@;
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| 189 | PU.5,3.5;LBBooklet 2014, Record Keeping and Reporting Guidelines.@;
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| 190 | PU.5,3;PD22,3;SD1,277,2,1,4,9,5,0,6,0,7,16901;
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| 191 | The CA-1 and CA-2 forms require a Hewlett Packard laser jet
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| 192 | (or compatible) printer with PCL (Printer Control Language)
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| 193 | Level 5. Do NOT select the home device.
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| 194 | NOTICE OF TRAUMATIC INJURY
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| 195 | CA-1
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| 196 | Federal Employee's Notice of Traumatic Injury and Claim for Continuation of
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| 197 | Pay/Compensation (Continued)
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| 198 | CA-2
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| 199 | Notice of Occupational Disease and Claim for Compensation (Continued)
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| 200 | Select case:
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| 201 | SUPERVISOR...................:
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| 202 | VOLUNTARY SVC SUPERVISOR.....:
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| 203 | CONTRACT ADMINISTRATOR.......:
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| 204 | SAFETY OFFICER...............:
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| 205 | CASE NUMBER..................:
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| 206 | PERSONNEL STATUS.............:
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| 207 | SERVICE......................:
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| 208 | TYPE OF INCIDENT.............:
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| 209 | CASE STATUS..................:
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| 210 | INJURY/ILLNESS...............:
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| 211 | PERSON INVOLVED..............:
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| 212 | SSN..........................:
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| 213 | DATE OF BIRTH................:
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| 214 | SEX..........................:
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| 215 | HOME ADDRESS.................:
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| 216 | HOME PHONE NUMBER............:
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| 217 | STATION NUMBER...............:
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| 218 | COST CENTER/ORG..............:
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| 219 | OCCUPATION...................:
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| 220 | GRADE/STEP...................:
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| 221 | EDUCATION....................:
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| 222 | SECONDARY SUPERVISOR.........:
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| 223 | DATE/TIME OF OCCURRENCE......:
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| 224 | GENERAL SETTING OF INCIDENT..:
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| 225 | LOCATION OF INCIDENT.........:
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| 226 | CHARACTERIZATION OF INJURY...:
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| 227 | MEDICAL EMERGENCY............:
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| 228 | BODY PART MOST AFFECTED......:
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| 229 | ADDITIONAL BODY PART AFFECTED:
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| 230 | SIDE OF BODY AFFECTED........:
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| 231 | DUTY RETURNED TO.............:
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| 232 | LOST TIME....................:
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| 233 | DESCRIPTION OF INCIDENT......:
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| 234 | PATIENT SOURCE...............:
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| 235 | CONTAMINATION................:
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| 236 | PURPOSE OF SHARP OBJECT......:
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| 237 | ACTIVITY AT TIME OF INJURY...:
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| 238 | OBJECT CAUSING INJURY........:
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| 239 | DEVICE SIZE..................:
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| 240 | BRAND........................:
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| 241 | AREA EXPOSED TO BODILY FLUID.:
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| 242 | PERSONAL PROTECTIVE EQUIPMENT:
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| 243 | BODILY FLUID EXPOSURE SOURCE.:
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| 244 | EQUIPMENT/DEVICE FAILURE.....:
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| 245 | SAFETY DESIGN DEVICE USED....:
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| 246 | DID INJURY OCCUR BEFORE
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| 247 | SAFETY DEVICE WAS ENGAGED...:
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| 248 | SAFETY CHARACTERISTICS.......:
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| 249 | EXPLAIN WHY SAFE DEV NOT USED:
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| 250 | CORRECTIVE ACTION............:
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| 251 | SAFETY OFF. COMMENTS.........:
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| 252 | PERSON ENTERING STUB RECORD..:
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| 253 | SUPERVISOR SIGNATURE DATE....:
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| 254 | /ES/SAFETY OFFICER...........:
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| 255 | SAFETY OFFICER SIGNATURE DATE:
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| 256 | ASISTS REPORT OF ACCIDENT
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| 257 | Report of Accident
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| 258 | Select the Fiscal Year or RETURN for ALL:
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| 259 | Enter the Fiscal Year that you want to print for or RETURN for data in file
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| 260 | You must enter a 4 digit year.
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| 261 | No date for that Fiscal Year please select again.
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| 262 | Print Accident Report Sign-off list
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| 263 | EMPLOYEE:
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| 264 | UN-
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| 265 | SUPERVISOR:
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| 266 | SAFETY OFFICER:
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| 267 | Accident Report Status
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| 268 | for the fiscal Year
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| 269 | DATE OF INCIDENT
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| 270 | Select Form:
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| 271 | Select the form to be printed.
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| 272 | Print a
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| 273 | Select Case:
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| 274 | 51 CASE STATUS..................//C
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| 275 | 47 CORRECTIVE ACTION TAKEN......
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| 276 | 55 SAFETY OFF. COMMENTS.........
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| 277 | The Employee portion of the CA
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| 278 | has not been signed.
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| 279 | The Supervisor portion of the CA
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| 280 | The Employee or Supervisor has not signed their
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| 281 | part of the CA Claim form.
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| 282 | Signing the form now closes the case and removes
|
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| 283 | it from everyone's selection list for editing.
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| 284 | Do you want to sign the Case
|
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| 285 | CASE STATUS..................
|
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| 286 | 58 REASON FOR DELETION.........
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| 287 | 1) VA FORM 2162
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| 288 | Injury (CA1
|
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| 289 | Illness (CA2
|
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| 290 | Select form:
|
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| 291 | Select the form to be edited.
|
|---|
| 292 | Another user is editing this entry. Try later.
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| 293 | The employee has not signed the
|
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| 294 | Supervisor must sign before Safety Officer
|
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| 295 | 230 19. AGENCY NAME...................//^S X=AGN;I X=
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| 296 | 231 STREET ADDRESS................//^S X=ADD
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| 297 | 234 AGENCY ZIP CODE...............//^S X=ZIP
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| 298 | 237 20. EMPLOYEE'S DUTY STATION.......
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| 299 | 238 STREET ADDRESS................
|
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| 300 | 241 ZIP CODE......................
|
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| 301 | 21. REGULAR WORK HOURS:
|
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| 302 | 22. REGULAR WORK SCHEDULE.........:
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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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