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			
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