| [604] | 1 | English French Notes Complete/Exclude
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| 2 | 23. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE
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| 3 | 245 NAME OF PHYSICIAN.............//^S X=PNAME;I X=
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| 4 | 246 STREET ADDRESS................//^S X=PADD
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| 5 | 249 ZIP CODE......................//^S X=PZIP
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| 6 | 250 24. 1ST DATE MEDICAL CARE RECEIVED
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| 7 | 251 25. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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| 8 | 252 26. DATE EMPLOYEE FIRST REPORTED CONDITION TO SUPERVISOR.
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| 9 | 253 27. DATE/TIME EMPLOYEE STOPPED WORK..
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| 10 | 254 28. DATE/TIME EMPLOYEE'S PAY STOPPED.
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| 11 | 255 29. DATE EMPLOYEE WAS LAST EXPOSED TO CONDITIONS ALLEGED TO HAVE CAUSED DISEASE OR ILLNESS...............
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| 12 | 256 30. DATE/TIME RETURNED TO WORK.......
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| 13 | 31. IF EMPLOYEE HAS RETURNED TO WORK AND WORK ASSIGNMENT HAS CHANGED, DESCRIBE NEW DUTIES
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| 14 | Invalid character entered, (~,`,@,#,$,%,^,*,_,|,\,},{,[,],>, or <),
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| 15 | . Please edit.
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| 16 | 61 OTHER RETIREMENT..............
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| 17 | 258 33. WAS INJURY CAUSED BY 3RD PARTY;I X=
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| 18 | 259 34. NAME OF THIRD PARTY...........
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| 19 | 260 STREET ADDRESS................
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| 20 | 263 ZIP CODE......................
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| 21 | Signature of Supervisor
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| 22 | NAME OF SUPERVISOR:
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| 23 | 269 OFFICE PHONE......
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| 24 | 26 GENERAL SETTING OF INCIDENT........;S X=X;
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| 25 | 27 LOCATION OF INJURY.................;S X=X;D CARE2^OOPSUTL2(IEN);
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| 26 | 28 DESCRIPTION OF INCIDENT............
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| 27 | 29.5 HOW IS INCIDENT RELATED TO MEDICAL EMERGENCY
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| 28 | 29 CHARACTERIZATION OF INJURY.........
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| 29 | 30 BODY PART MOST AFFECTED............
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| 30 | 30.1 ADDITIONAL BODY PART AFFECTED......
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| 31 | 31 SIDE OF BODY AFFECTED..............;S X=X;
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| 32 | 34 PATIENT SOURCE.....................
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| 33 | 36 PURPOSE OF SHARP OBJECT...........
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| 34 | 37 ACTIVITY AT TIME OF INJURY........
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| 35 | 38 OBJECT CAUSING INJURY.............;S X=X;
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| 36 | 83 DEVICE SIZE.......................
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| 37 | 41 BODILY FLUID EXPOSURE SOURCE.......
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| 38 | 42.5 WAS THERE AN EQUIPMENT/DEVICE/PRODUCT FAILURE//^S X=FAIL;I X=
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| 39 | 42 DESCRIBE EQUIPMENT/DEVICE/PRODUCT FAILURE..
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| 40 | 43 SAFETY DESIGN DEVICE USED....;S X=X;
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| 41 | 87 DID THE INJURY OCCUR BEFORE THE SAFETY DEVICE WAS ENGAGED..
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| 42 | 84 SAFETY CHARACTERISTICS.......
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| 43 | 85 EXPLAIN WHY A SAFETY DEVICE WAS NOT USED...
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| 44 | 32 DUTY RETURNED TO...................
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| 45 | 33 LOST TIME..........................;S X=X;
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| 46 | 47 CORRECTIVE ACTION............
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| 47 | for Continuation of Pay/Compensation (Form CA-1)
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| 48 | 130 17. AGENCY NAME...............//^S X=AGN;I X=
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| 49 | 131 STREET ADDRESS............//^S X=ADD
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| 50 | 134 ZIP CODE..................//^S X=ZIP
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| 51 | 176 18. EMPLOYEE'S DUTY STATION...
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| 52 | 177 STREET ADDRESS............
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| 53 | 180 ZIP CODE..................
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| 54 | 61 OTHER RETIREMENT...........
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| 55 | 20. REGULAR WORK HOURS:
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| 56 | 21. REGULAR WORK SCHEDULE.....:
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| 57 | 4 22. DATE/TIME INJURY OCCURRED.......//^S X=DTINJ
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| 58 | 175 23. DATE OF NOTICE RECEIVED...//^S X=DT110
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| 59 | 142 24. DATE/TIME STOPPED WORK....
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| 60 | 143 25. DATE PAY STOPPED..........
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| 61 | 144 26. DATE 45 DAY PERIOD BEGAN..
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| 62 | 145 27. DATE/TIME RETURNED TO WORK
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| 63 | 146 28. WAS EMPLOYEE INJURED IN PERFORMANCE OF DUTY;I X=
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| 64 | 148 29. WAS INJURY CAUSED BY EMPLOYEE'S WILLFUL MISCONDUCT, INTOXICATION, OR INTENT TO INJURE SELF OR ANOTHER;I X=
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| 65 | 150 30. WAS INJURY CAUSED BY 3RD PARTY;I X=
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| 66 | 31. NAME AND ADDRESS OF THIRD PARTY:
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| 67 | 151 NAME OF THIRD PARTY.......;I X=
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| 68 | 152 STREET ADDRESS............
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| 69 | 155 ZIP CODE..................
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| 70 | 32. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE:
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| 71 | 156 NAME OF PHYSICIAN.........//^S X=PNAME;I X=
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| 72 | 157 STREET ADDRESS............//^S X=PADD
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| 73 | 160 ZIP CODE..................//^S X=PZIP
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| 74 | 161 33. 1ST DATE MEDICAL CARE RECEIVED
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| 75 | 162 34. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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| 76 | 163 35. DOES YOUR KNOWLEDGE OF THE FACTS AGREE WITH STATEMENTS OF THE EMPLOYEE;I X=
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| 77 | 165 36. IF THE EMPLOYING AGENCY CONTROVERTS CONTINUATION OF PAY, STATE THE REASON IN DETAIL~
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| 78 | 37. PAY RATE WHEN EMPLOYEE STOPPED WORK:
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| 79 | Signature of Supervisor and Filing Instructions
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| 80 | NAME OF SUPERVISOR:
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| 81 | 173 OFFICE PHONE.......
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| 82 | 174 39. FILING INSTRUCTIONS
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| 83 | Required Cross Reference (
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| 84 | ) was not set up, call your IRM.
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| 85 | ) was not properly destroyed, call your IRM.
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| 86 | Select Forms:
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| 87 | form CA1 (Injury)
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| 88 | form CA2 (Illness)
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| 89 | Select Forms
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| 90 | WCES;1,3
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| 91 | CA1ES;4,6
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| 92 | CA2ES;4,6
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| 93 | CA1ES;1,3
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| 94 | CA2ES;1,3
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| 95 | Your ES has been cleared. You will need to resign.
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| 96 | Invalid character entered (~,`,@,#,$,%,*,_,|,\,},{,[,],>, or <)
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| 97 | WAS THERE AN EQUIPMENT/DEVICE/PRODUCT FAILURE
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| 98 | Enter Yes or No to indicate that it was a failure of an device.
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| 99 | Was the exposed part:
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| 100 | Select the Area Type:
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| 101 | GENERAL SETTING OF
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| 102 | Select the area type to be used.
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| 103 | NON-PATIENT
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| 104 | CARE AREA:
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| 105 | Enter the employee's work schedule at the time of the incident.
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| 106 | The numbers 1-7 correspond to the days of the week.
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| 107 | Enter the day numbers as a range or list separated by commas.
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| 108 | Examples: For Mon-Fri enter 2-6 (or 2,3,4,5,6)
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| 109 | For Wed-Sat enter 4-7 (or 4,5,6,7)
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| 110 | For Mon,Wed,Fri enter 2,4,6
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| 111 | Range exceeds 1-7 limit.
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| 112 | . A supervisor who knowingly certifies to any false statement,
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| 113 | misrepresentation, concealment of fact, etc., in respect of
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| 114 | this claim may also be subject to appropriate felony criminal
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| 115 | I certify that the information given above and that furnished
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| 116 | by the employee is true to the best of my knowledge with the
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| 117 | following exception.
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| 118 | Sun,Mon,Tue,Wed,Thu,Fri,Sat
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| 119 | cannot be more than
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| 120 | years in the past.
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| 121 | DOB cannot be after
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| 122 | Enter the person's name, using the format LASTNAME,FIRSTNAME.
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| 123 | Suffixes such as Sr, Jr, III can only be entered as a FIRSTNAME.
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| 124 | There must be a LAST NAME and FIRST NAME separated by a comma.
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| 125 | Spaces in the last name are not allowed and the only
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| 126 | punctuation allowed is a hyphen (-) or comma (,).
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| 127 | Witness Data is incomplete for the following Witnesses, enter missing data.
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| 128 | is missing the
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| 129 | Date of Witness Signature cannot be prior to DATE/TIME OF OCCURRENCE.
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| 130 | Address or City contains invalid characters:
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| 131 | (~,`,@,#,$,%,*,_,|,\,},{,[,],>,or <). Please Edit
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| 132 | YOU LAST SELECTED:
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| 133 | . REGULAR WORK SCHEDULE:
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| 134 | SELECT THE DAYS OF THE WEEK:
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| 135 | ENTER THE NUMBER OF THE DAY/S OF THE WEEK WORKED
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| 136 | 1-3,6,7 WOULD BE:
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| 137 | SUNDAY THRU TUESDAY, FRIDAY AND SATURDAY.
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| 138 | cannot be blank if date entered in
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| 139 | Validating data on form
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| 140 | This date cannot be prior to DATE/TIME INJURY OCCURRED entered on 2162.
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| 141 | Invalid Physician Name format.
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| 142 | Invalid Witness Name format.
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| 143 | REASON FOR CONTROVERT COP exceeds 528 character limit set by DOL.
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| 144 | SUPERVISOR NOT AGREE EXPLAIN exceeds 528 character limit set by DOL.
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| 145 | RELATIONSHIP OF ILLNESS TO EMP exceeds 528 character limit set by DOL.
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| 146 | NATURE OF DISEASE/ILLNESS exceededs 264 character limit set by DOL.
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| 147 | CLAIM NOT FILED exceeds 528 character limit set by DOL.
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| 148 | EMPLOYEE STATEMENT DELAYED exceeds 528 character limit set by DOL.
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| 149 | MEDICAL REPORT DELAYED exceeds 528 character limit set by DOL.
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| 150 | WORK DUTY CHANGED exceeds 528 character limit set by DOL.
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| 151 | OOPS SIGNATURE SECURITY
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| 152 | OK to transmit to DOL
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| 153 | My consent is given for the release of case number
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| 154 | information for review by local bargaining units for accident and
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| 155 | illness tracking purposes only. Name, address, social security
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| 156 | number, date of birth, and telephone number will not be included
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| 157 | in the information provided to the bargaining units.
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| 158 | With your consent, the following information will be provided
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| 159 | to the local bargaining unit for your review.
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| 160 | Dt/Tme Occurrence:
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| 161 | Personnel Status:
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| 162 | Station Number:
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| 163 | Cost Center/Org:
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| 164 | Type Incid:
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| 165 | Secondary Super:
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| 166 | 72Consent Given://^S X=
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| 167 | If you give consent, you will be prompted to select the
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| 168 | Union to send the bulletin to. The bulletin will be sent
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| 169 | immediately after the Union has been selected.
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| 170 | Select UNION to send bulletin to:
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| 171 | Cannot sent a bulletin to Union, No Union Representative name was selected
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| 172 | or one is not on file. Contact your Workers' Compensation Specialist.
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| 173 | You '^'d out, Do you want to Sign
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| 174 | OOPS(2260,IEN,
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| 175 | Are you signing for the Supervisor
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| 176 | The Supervisor has not signed the
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| 177 | . To continue
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| 178 | editing, you will need to sign as Supervisor.
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| 179 | Sign as Supervisor
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| 180 | Supervisor has not signed
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| 181 | This person is not in the PAID Employee File and does not appear
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| 182 | eligible to submit a claim to DOL. Please check with your
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| 183 | Human Resources Department for assistance. Sending a paper
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| 184 | hardcopy may be necessary, if allowable.
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| 185 | This person does not appear to be eligible for submitting a claim
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| 186 | to DOL, please review the RETIREMENT, GRADE, STEP, PAY
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| 187 | PLAN, PAY RATE and PAY RATE PER Fields. You may need to
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| 188 | contact your Human Resources Department or IRM for assistance.
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| 189 | Worker's Comp edit of special fields occurred, Supervisor
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| 190 | signature fields cleared, you will need to sign as Supervisor.
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| 191 | Worker's Compensation Signing for Supervisor
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| 192 | Signature of Supervisor and Filing Instructions
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| 193 | NAME OF SUPERVISOR.:
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| 194 | 173 OFFICE PHONE.......;I X=
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| 195 | Worker's Comp Edit of Supervisor's Report
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| 196 | 73 OWCP DISTRICT OFFICE......//^S X=WCPDO
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| 197 | 70 OWCP CHARGEBACK CODE......//^S X=OWCP
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| 198 | 62 OWCP NOI CODE.............
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| 199 | NOI Code must begin with a T for a CA1.
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| 200 | 122 14a. OCCUPATION CODE...........
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| 201 | 123 14b. TYPE CODE.................
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| 202 | 124 14c. SOURCE CODE...............
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| 203 | 130 17. AGENCY NAME...............//^S X=AGN;I X=
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| 204 | 131 STREET ADDRESS............//^S X=ADD
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| 205 | 134 ZIP CODE..................//^S X=ZIP
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| 206 | 176 18. EMPLOYEE'S DUTY STATION...
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| 207 | 177 STREET ADDRESS............
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| 208 | 180 ZIP CODE..................
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| 209 | 61 OTHER RETIREMENT..........
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| 210 | 20. REGULAR WORK HOURS:
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| 211 | 21. REGULAR WORK SCHEDULE.....:
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| 212 | 4 22. DATE/TIME INJURY OCCURRED.......//^S X=DTINJ
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| 213 | 175 23. DATE OF NOTICE RECEIVED...//^S X=DT110
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| 214 | 142 24. DATE/TIME STOPPED WORK....
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| 215 | 143 25. DATE PAY STOPPED..........
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| 216 | 144 26. DATE 45 DAY PERIOD BEGAN..
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| 217 | 145 27. DATE/TIME RETURNED TO WORK
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| 218 | 146 28. WAS EMPLOYEE INJURED IN PERFORMANCE OF DUTY;I X=
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| 219 | 148 29. WAS INJURY CAUSED BY EMPLOYEE'S WILLFUL MISCONDUCT, INTOXICATION, OR INTENT TO INJURE SELF OR ANOTHER;I X=
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| 220 | 150 30. WAS INJURY CAUSED BY 3RD PARTY;I X=
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| 221 | 31. NAME AND ADDRESS OF THIRD PARTY:
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| 222 | 151 NAME OF THIRD PARTY.......;I X=
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| 223 | 152 STREET ADDRESS............
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| 224 | 155 ZIP CODE..................
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| 225 | 32. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE:
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| 226 | 156 NAME OF PHYSICIAN.........//^S X=PNAME;I X=
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| 227 | 157 STREET ADDRESS............//^S X=PADD
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| 228 | 160 ZIP CODE..................//^S X=PZIP
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| 229 | 161 33. 1ST DATE MEDICAL CARE RECEIVED
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| 230 | 162 34. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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| 231 | 163 35. DOES YOUR KNOWLEDGE OF THE FACTS AGREE WITH STATEMENTS OF THE EMPLOYEE;I X=
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| 232 | 165.1 36a. DOES THE AGENCY CONTROVERT THIS CLAIM;S CONT=X
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| 233 | 165.2 36b. DOES THE AGENCY DISPUTE THIS CLAIM...
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| 234 | 165 36. IF THE EMPLOYING AGENCY CONTROVERTS CONTINUATION OF PAY, STATE THE REASON IN DETAIL~
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| 235 | 37. PAY RATE WHEN EMPLOYEE STOPPED WORK:
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| 236 | 174 39. FILING INSTRUCTIONS
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| 237 | Worker's Comp Edit of the Supervisor's Report
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| 238 | NOI Code cannot begin with a T for a CA2.
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| 239 | 224 9a. OCCUPATION CODE...............
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| 240 | 226 14b. TYPE CODE.....................
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| 241 | 227 14c. SOURCE CODE...................
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| 242 | 230 19. AGENCY NAME...................//^S X=AGN;I X=
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| 243 | 231 STREET ADDRESS................//^S X=ADD
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| 244 | 234 AGENCY ZIP CODE...............//^S X=ZIP
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| 245 | 237 20. EMPLOYEE'S DUTY STATION.......
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| 246 | 238 STREET ADDRESS................
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| 247 | 241 ZIP CODE......................
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| 248 | 21. REGULAR WORK HOURS:
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| 249 | 22. REGULAR WORK SCHEDULE.........:
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| 250 | 23. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE
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| 251 | 245 NAME OF PHYSICIAN.............//^S X=PNAME;I X=
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| 252 | 246 STREET ADDRESS................//^S X=PADD
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| 253 | 249 ZIP CODE......................//^S X=PZIP
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| 254 | 270 PHYSICIAN TITLE...............//^S X=PTITLE
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| 255 | 250 24. 1ST DATE MEDICAL CARE RECEIVED
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| 256 | 251 25. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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| 257 | 252 26. DATE EMPLOYEE FIRST REPORTED CONDITION TO SUPERVISOR.
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| 258 | 253 27. DATE/TIME EMPLOYEE STOPPED WORK..
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| 259 | 254 28. DATE/TIME EMPLOYEE'S PAY STOPPED.
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| 260 | 255 29. DATE EMPLOYEE WAS LAST EXPOSED TO CONDITIONS ALLEGED TO HAVE CAUSED DISEASE OR ILLNESS...............
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| 261 | 256 30. DATE/TIME RETURNED TO WORK.......
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| 262 | 31. IF EMPLOYEE HAS RETURNED TO WORK AND WORK ASSIGNMENT HAS CHANGED, DESCRIBE NEW DUTIES
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| 263 | Invalid character entered, (~,`,@ ,#,$,%,^,*,_,|,\,},{,[,],>, or <),
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| 264 | Workers Comp signing for Supervisor
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| 265 | if you continue, your ES will be removed
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| 266 | The SAFETY DEVICE USED Field (#43) in the ASISTS ACCIDENT REPORTING
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| 267 | File (#2260) has been changed. Unknown has been removed as a
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| 268 | valid code for this field. All records with Unknown will be
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| 269 | changed to 'N'o.
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| 270 | OOPS*1.0*11
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| 271 | Data Conversion in Progress...
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| 272 | Safety Device changed from Unknown to No for this case
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| 273 | Station # for Case #:
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| 274 | , could not be Converted,
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| 275 | Update Manually.
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| 276 | ASISTS Cases have been Updated with Station Number.
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| 277 | Hollow Bore Needlestick
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| 278 | Exposure to Body Fluids/Splash
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| 279 | Suture Needlestick
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| 280 | Drill bit/burr
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| 281 | Blunt Suture Needle
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| 282 | Table Files have been Updated.
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| 283 | The PAY RATE PER Field (#167) in the ASISTS ACCIDENT REPORTING
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| 284 | File (#2260) has been changed from a free text field to a
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| 285 | set of codes field.
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| 286 | This routine will convert the current data in the PAY RATE PER
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| 287 | field for cases that a valid code can be determined.
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| 288 | The Set of Codes are:
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| 289 | Any case that the correct code cannot be determined for will
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| 290 | be included in the install file and the PAY RATE PER data deleted.
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| 291 | An option is provided with the patch that will allow
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| 292 | a user to correct the data after installation of the patch.
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| 293 | If required (cases are present with data that could not be
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| 294 | converted), install the option as a secondary menu on the
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| 295 | appropriate users' menu and instruct them to make the data
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| 296 | OOPS*1.0*8
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| 297 | Pay Rate Per cannot be converted for Case
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| 298 | Pay Rate Per Conversion complete.
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| 299 | Table updates completed.
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| 300 | Modifying ASISTS DOL CAUSE OF INJURY CODE Table File (#2263.2)
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| 301 | Modifying ASISTS DOL SOURCE OF INJURY CODES Table File (#2263.1)
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| 302 | Hand tool (powered: saw
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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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