English French Notes Complete/Exclude 23. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE 245 NAME OF PHYSICIAN.............//^S X=PNAME;I X= 246 STREET ADDRESS................//^S X=PADD 249 ZIP CODE......................//^S X=PZIP 250 24. 1ST DATE MEDICAL CARE RECEIVED 251 25. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK 252 26. DATE EMPLOYEE FIRST REPORTED CONDITION TO SUPERVISOR. 253 27. DATE/TIME EMPLOYEE STOPPED WORK.. 254 28. DATE/TIME EMPLOYEE'S PAY STOPPED. 255 29. DATE EMPLOYEE WAS LAST EXPOSED TO CONDITIONS ALLEGED TO HAVE CAUSED DISEASE OR ILLNESS............... 256 30. DATE/TIME RETURNED TO WORK....... 31. IF EMPLOYEE HAS RETURNED TO WORK AND WORK ASSIGNMENT HAS CHANGED, DESCRIBE NEW DUTIES Invalid character entered, (~,`,@,#,$,%,^,*,_,|,\,},{,[,],>, or <), . Please edit. 61 OTHER RETIREMENT.............. 258 33. WAS INJURY CAUSED BY 3RD PARTY;I X= 259 34. NAME OF THIRD PARTY........... 260 STREET ADDRESS................ 263 ZIP CODE...................... Signature of Supervisor NAME OF SUPERVISOR: 269 OFFICE PHONE...... 26 GENERAL SETTING OF INCIDENT........;S X=X; 27 LOCATION OF INJURY.................;S X=X;D CARE2^OOPSUTL2(IEN); 28 DESCRIPTION OF INCIDENT............ 29.5 HOW IS INCIDENT RELATED TO MEDICAL EMERGENCY 29 CHARACTERIZATION OF INJURY......... 30 BODY PART MOST AFFECTED............ 30.1 ADDITIONAL BODY PART AFFECTED...... 31 SIDE OF BODY AFFECTED..............;S X=X; 34 PATIENT SOURCE..................... 36 PURPOSE OF SHARP OBJECT........... 37 ACTIVITY AT TIME OF INJURY........ 38 OBJECT CAUSING INJURY.............;S X=X; 83 DEVICE SIZE....................... 41 BODILY FLUID EXPOSURE SOURCE....... 42.5 WAS THERE AN EQUIPMENT/DEVICE/PRODUCT FAILURE//^S X=FAIL;I X= 42 DESCRIBE EQUIPMENT/DEVICE/PRODUCT FAILURE.. 43 SAFETY DESIGN DEVICE USED....;S X=X; 87 DID THE INJURY OCCUR BEFORE THE SAFETY DEVICE WAS ENGAGED.. 84 SAFETY CHARACTERISTICS....... 85 EXPLAIN WHY A SAFETY DEVICE WAS NOT USED... 32 DUTY RETURNED TO................... 33 LOST TIME..........................;S X=X; 47 CORRECTIVE ACTION............ for Continuation of Pay/Compensation (Form CA-1) 130 17. AGENCY NAME...............//^S X=AGN;I X= 131 STREET ADDRESS............//^S X=ADD 134 ZIP CODE..................//^S X=ZIP 176 18. EMPLOYEE'S DUTY STATION... 177 STREET ADDRESS............ 180 ZIP CODE.................. 61 OTHER RETIREMENT........... 20. REGULAR WORK HOURS: 21. REGULAR WORK SCHEDULE.....: 4 22. DATE/TIME INJURY OCCURRED.......//^S X=DTINJ 175 23. DATE OF NOTICE RECEIVED...//^S X=DT110 142 24. DATE/TIME STOPPED WORK.... 143 25. DATE PAY STOPPED.......... 144 26. DATE 45 DAY PERIOD BEGAN.. 145 27. DATE/TIME RETURNED TO WORK 146 28. WAS EMPLOYEE INJURED IN PERFORMANCE OF DUTY;I X= 148 29. WAS INJURY CAUSED BY EMPLOYEE'S WILLFUL MISCONDUCT, INTOXICATION, OR INTENT TO INJURE SELF OR ANOTHER;I X= 150 30. WAS INJURY CAUSED BY 3RD PARTY;I X= 31. NAME AND ADDRESS OF THIRD PARTY: 151 NAME OF THIRD PARTY.......;I X= 152 STREET ADDRESS............ 155 ZIP CODE.................. 32. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE: 156 NAME OF PHYSICIAN.........//^S X=PNAME;I X= 157 STREET ADDRESS............//^S X=PADD 160 ZIP CODE..................//^S X=PZIP 161 33. 1ST DATE MEDICAL CARE RECEIVED 162 34. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK 163 35. DOES YOUR KNOWLEDGE OF THE FACTS AGREE WITH STATEMENTS OF THE EMPLOYEE;I X= 165 36. IF THE EMPLOYING AGENCY CONTROVERTS CONTINUATION OF PAY, STATE THE REASON IN DETAIL~ 37. PAY RATE WHEN EMPLOYEE STOPPED WORK: Signature of Supervisor and Filing Instructions NAME OF SUPERVISOR: 173 OFFICE PHONE....... 174 39. FILING INSTRUCTIONS Required Cross Reference ( ) was not set up, call your IRM. ) was not properly destroyed, call your IRM. Select Forms: form CA1 (Injury) form CA2 (Illness) Select Forms WCES;1,3 CA1ES;4,6 CA2ES;4,6 CA1ES;1,3 CA2ES;1,3 Your ES has been cleared. You will need to resign. Invalid character entered (~,`,@,#,$,%,*,_,|,\,},{,[,],>, or <) WAS THERE AN EQUIPMENT/DEVICE/PRODUCT FAILURE Enter Yes or No to indicate that it was a failure of an device. Was the exposed part: Select the Area Type: GENERAL SETTING OF Select the area type to be used. NON-PATIENT CARE AREA: Enter the employee's work schedule at the time of the incident. The numbers 1-7 correspond to the days of the week. Enter the day numbers as a range or list separated by commas. Examples: For Mon-Fri enter 2-6 (or 2,3,4,5,6) For Wed-Sat enter 4-7 (or 4,5,6,7) For Mon,Wed,Fri enter 2,4,6 Range exceeds 1-7 limit. . A supervisor who knowingly certifies to any false statement, misrepresentation, concealment of fact, etc., in respect of this claim may also be subject to appropriate felony criminal I certify that the information given above and that furnished by the employee is true to the best of my knowledge with the following exception. Sun,Mon,Tue,Wed,Thu,Fri,Sat cannot be more than years in the past. DOB cannot be after Enter the person's name, using the format LASTNAME,FIRSTNAME. Suffixes such as Sr, Jr, III can only be entered as a FIRSTNAME. There must be a LAST NAME and FIRST NAME separated by a comma. Spaces in the last name are not allowed and the only punctuation allowed is a hyphen (-) or comma (,). Witness Data is incomplete for the following Witnesses, enter missing data. is missing the Date of Witness Signature cannot be prior to DATE/TIME OF OCCURRENCE. Address or City contains invalid characters: (~,`,@,#,$,%,*,_,|,\,},{,[,],>,or <). Please Edit YOU LAST SELECTED: . REGULAR WORK SCHEDULE: SELECT THE DAYS OF THE WEEK: ENTER THE NUMBER OF THE DAY/S OF THE WEEK WORKED 1-3,6,7 WOULD BE: SUNDAY THRU TUESDAY, FRIDAY AND SATURDAY. cannot be blank if date entered in Validating data on form This date cannot be prior to DATE/TIME INJURY OCCURRED entered on 2162. Invalid Physician Name format. Invalid Witness Name format. REASON FOR CONTROVERT COP exceeds 528 character limit set by DOL. SUPERVISOR NOT AGREE EXPLAIN exceeds 528 character limit set by DOL. RELATIONSHIP OF ILLNESS TO EMP exceeds 528 character limit set by DOL. NATURE OF DISEASE/ILLNESS exceededs 264 character limit set by DOL. CLAIM NOT FILED exceeds 528 character limit set by DOL. EMPLOYEE STATEMENT DELAYED exceeds 528 character limit set by DOL. MEDICAL REPORT DELAYED exceeds 528 character limit set by DOL. WORK DUTY CHANGED exceeds 528 character limit set by DOL. OOPS SIGNATURE SECURITY OK to transmit to DOL My consent is given for the release of case number information for review by local bargaining units for accident and illness tracking purposes only. Name, address, social security number, date of birth, and telephone number will not be included in the information provided to the bargaining units. With your consent, the following information will be provided to the local bargaining unit for your review. Dt/Tme Occurrence: Personnel Status: Station Number: Cost Center/Org: Type Incid: Secondary Super: 72Consent Given://^S X= If you give consent, you will be prompted to select the Union to send the bulletin to. The bulletin will be sent immediately after the Union has been selected. Select UNION to send bulletin to: Cannot sent a bulletin to Union, No Union Representative name was selected or one is not on file. Contact your Workers' Compensation Specialist. You '^'d out, Do you want to Sign OOPS(2260,IEN, Are you signing for the Supervisor The Supervisor has not signed the . To continue editing, you will need to sign as Supervisor. Sign as Supervisor Supervisor has not signed This person is not in the PAID Employee File and does not appear eligible to submit a claim to DOL. Please check with your Human Resources Department for assistance. Sending a paper hardcopy may be necessary, if allowable. This person does not appear to be eligible for submitting a claim to DOL, please review the RETIREMENT, GRADE, STEP, PAY PLAN, PAY RATE and PAY RATE PER Fields. You may need to contact your Human Resources Department or IRM for assistance. Worker's Comp edit of special fields occurred, Supervisor signature fields cleared, you will need to sign as Supervisor. Worker's Compensation Signing for Supervisor Signature of Supervisor and Filing Instructions NAME OF SUPERVISOR.: 173 OFFICE PHONE.......;I X= Worker's Comp Edit of Supervisor's Report 73 OWCP DISTRICT OFFICE......//^S X=WCPDO 70 OWCP CHARGEBACK CODE......//^S X=OWCP 62 OWCP NOI CODE............. NOI Code must begin with a T for a CA1. 122 14a. OCCUPATION CODE........... 123 14b. TYPE CODE................. 124 14c. SOURCE CODE............... 130 17. AGENCY NAME...............//^S X=AGN;I X= 131 STREET ADDRESS............//^S X=ADD 134 ZIP CODE..................//^S X=ZIP 176 18. EMPLOYEE'S DUTY STATION... 177 STREET ADDRESS............ 180 ZIP CODE.................. 61 OTHER RETIREMENT.......... 20. REGULAR WORK HOURS: 21. REGULAR WORK SCHEDULE.....: 4 22. DATE/TIME INJURY OCCURRED.......//^S X=DTINJ 175 23. DATE OF NOTICE RECEIVED...//^S X=DT110 142 24. DATE/TIME STOPPED WORK.... 143 25. DATE PAY STOPPED.......... 144 26. DATE 45 DAY PERIOD BEGAN.. 145 27. DATE/TIME RETURNED TO WORK 146 28. WAS EMPLOYEE INJURED IN PERFORMANCE OF DUTY;I X= 148 29. WAS INJURY CAUSED BY EMPLOYEE'S WILLFUL MISCONDUCT, INTOXICATION, OR INTENT TO INJURE SELF OR ANOTHER;I X= 150 30. WAS INJURY CAUSED BY 3RD PARTY;I X= 31. NAME AND ADDRESS OF THIRD PARTY: 151 NAME OF THIRD PARTY.......;I X= 152 STREET ADDRESS............ 155 ZIP CODE.................. 32. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE: 156 NAME OF PHYSICIAN.........//^S X=PNAME;I X= 157 STREET ADDRESS............//^S X=PADD 160 ZIP CODE..................//^S X=PZIP 161 33. 1ST DATE MEDICAL CARE RECEIVED 162 34. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK 163 35. DOES YOUR KNOWLEDGE OF THE FACTS AGREE WITH STATEMENTS OF THE EMPLOYEE;I X= 165.1 36a. DOES THE AGENCY CONTROVERT THIS CLAIM;S CONT=X 165.2 36b. DOES THE AGENCY DISPUTE THIS CLAIM... 165 36. IF THE EMPLOYING AGENCY CONTROVERTS CONTINUATION OF PAY, STATE THE REASON IN DETAIL~ 37. PAY RATE WHEN EMPLOYEE STOPPED WORK: 174 39. FILING INSTRUCTIONS Worker's Comp Edit of the Supervisor's Report NOI Code cannot begin with a T for a CA2. 224 9a. OCCUPATION CODE............... 226 14b. TYPE CODE..................... 227 14c. SOURCE CODE................... 230 19. AGENCY NAME...................//^S X=AGN;I X= 231 STREET ADDRESS................//^S X=ADD 234 AGENCY ZIP CODE...............//^S X=ZIP 237 20. EMPLOYEE'S DUTY STATION....... 238 STREET ADDRESS................ 241 ZIP CODE...................... 21. REGULAR WORK HOURS: 22. REGULAR WORK SCHEDULE.........: 23. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE 245 NAME OF PHYSICIAN.............//^S X=PNAME;I X= 246 STREET ADDRESS................//^S X=PADD 249 ZIP CODE......................//^S X=PZIP 270 PHYSICIAN TITLE...............//^S X=PTITLE 250 24. 1ST DATE MEDICAL CARE RECEIVED 251 25. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK 252 26. DATE EMPLOYEE FIRST REPORTED CONDITION TO SUPERVISOR. 253 27. DATE/TIME EMPLOYEE STOPPED WORK.. 254 28. DATE/TIME EMPLOYEE'S PAY STOPPED. 255 29. DATE EMPLOYEE WAS LAST EXPOSED TO CONDITIONS ALLEGED TO HAVE CAUSED DISEASE OR ILLNESS............... 256 30. DATE/TIME RETURNED TO WORK....... 31. IF EMPLOYEE HAS RETURNED TO WORK AND WORK ASSIGNMENT HAS CHANGED, DESCRIBE NEW DUTIES Invalid character entered, (~,`,@ ,#,$,%,^,*,_,|,\,},{,[,],>, or <), Workers Comp signing for Supervisor if you continue, your ES will be removed The SAFETY DEVICE USED Field (#43) in the ASISTS ACCIDENT REPORTING File (#2260) has been changed. Unknown has been removed as a valid code for this field. All records with Unknown will be changed to 'N'o. OOPS*1.0*11 Data Conversion in Progress... Safety Device changed from Unknown to No for this case Station # for Case #: , could not be Converted, Update Manually. ASISTS Cases have been Updated with Station Number. Hollow Bore Needlestick Exposure to Body Fluids/Splash Suture Needlestick Drill bit/burr Blunt Suture Needle Table Files have been Updated. The PAY RATE PER Field (#167) in the ASISTS ACCIDENT REPORTING File (#2260) has been changed from a free text field to a set of codes field. This routine will convert the current data in the PAY RATE PER field for cases that a valid code can be determined. The Set of Codes are: Any case that the correct code cannot be determined for will be included in the install file and the PAY RATE PER data deleted. An option is provided with the patch that will allow a user to correct the data after installation of the patch. If required (cases are present with data that could not be converted), install the option as a secondary menu on the appropriate users' menu and instruct them to make the data OOPS*1.0*8 Pay Rate Per cannot be converted for Case Pay Rate Per Conversion complete. Table updates completed. Modifying ASISTS DOL CAUSE OF INJURY CODE Table File (#2263.2) Modifying ASISTS DOL SOURCE OF INJURY CODES Table File (#2263.1) Hand tool (powered: saw #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################