English	French	Notes	Complete/Exclude
    INITIAL DOSE..................: 			
    SECOND DOSE...................: 			
  ADJUVANT CHEMO W BEAM RADIATION.: 			
  THYROID HORMONE THERAPY.........: 			
 Date of 1st course of tx....: 			
 Date of 1st Surgical Proc...: 			
 Surgery of primary site F...: 			
 Surgery of primary site @fac F: 			
 Radiation therapy to CNS....: 			
 Hormone therapy.............: 			
 Hormone therapy @fac........: 			
 Other treatment.............: 			
 Other treatment @fac........: 			
SURGICAL DX/STAGING PROC DATE: 99/99/9999			
Unknown;			
SURGICAL PROC/OTHER SITE DATE..: 			
DATE RADIATION STARTED:......: 			
LOCATION OF RADIATION........: 			
RADIATION TREATMENT VOLUME...: 			
REGIONAL TREATMENT MODALITY..: 			
REGIONAL DOSE:cGy............: 			
BOOST TREATMENT MODALITY.....: 			
BOOST DOSE:cGy...............: 			
NUMBER OF TREATMENTS.........: 			
DATE RADIATION ENDED.........: 			
CHEMOTHERAPY DATE:.............: 			
HORMONE THERAPY DATE:..........: 			
IMMUNOTHERAPY DATE:............: 			
HEMA TRANS/ENDOCRINE PROC DATE.: 			
SURG PROC/OTHER SIT @FAC...(R): 			
SURGICAL PROC/OTHER SITE @FAC..: 			
RADIATION @FAC...............: 			
RADIATION @FAC DATE..........: 			
CHEMOTHERAPY @FAC..............: 			
CHEMOTHERAPY @FAC DATE.........: 			
HORMONE THERAPY @FAC...........: 			
HORMONE THERAPY @FAC DATE......: 			
IMMUNOTHERAPY @FAC.............: 			
IMMUNOTHERAPY @FAC DATE........: 			
Select case to be amended: 			
Case number 			
 has been assigned to this amended incident.			
Use option 			
Edit Report of Incident			
 to complete this case.			
NAME OF EMPLOYEE...............: 			
SSN............................: 			
DOB............................: 			
SEX............................: 			
HOME TELEPHONE.................: 			
GRADE/STEP.....................: 			
PAY PLAN.......................: 			
EMPLOYEE'S ADDRESS.............: 			
CITY...........................: 			
STATE..........................: 			
ZIP............................: 			
DEPENDENTS.....................: 			
PLACE WHERE INJURY OCCURRED....: 			
STREET WHERE INJURY OCCURRED...: 			
CITY WHERE INJURY OCCURRED.....: 			
STATE WHERE INJURY OCCURRED....: 			
ZIP CODE WHERE INJURY OCCURRED.: 			
DATE/TIME OF OCCURRENCE........: 			
DATE OF THIS NOTICE............: 			
EMPLOYEE'S OCCUPATION..........: 			
CAUSE OF INJURY CODE...........: 			
CAUSE OF INJURY................: 			
NATURE OF INJURY...............: 			
REQUEST PAY OR LEAVE...........: 			
EMPLOYEE DATE OF SIGNATURE.....: 			
WITNESS INFORMATION:			
NAME OF WITNESS................: 			
WITNESS ADDRESS................: 			
WITNESS CITY...................: 			
WITNESS STATE..................: 			
WITNESS ZIP CODE...............: 			
DATE OF WITNESS SIGNATURE......: 			
STATEMENT OF WITNESS...........: 			
OCCUPATION CODE................: 			
NOI CODE.......................: 			
TYPE CODE......................: 			
SOURCE CODE....................: 			
OWCP CHARGEBACK CODE...........: 			
AGENCY NAME....................: 			
AGENCY ADDRESS.................: 			
AGENCY CITY....................: 			
AGENCY STATE...................: 			
AGENCY ZIP CODE................: 			
EMPLOYEE'S DUTY STATION........: 			
DUTY STATION ADDRESS...........: 			
DUTY STATION CITY..............: 			
DUTY STATION STATE.............: 			
DUTY STATION ZIP CODE..........: 			
EMPLOYEE RETIREMENT COVERAGE...: 			
EMP RETIREMENT COVERAGE DESC...: 			
REGULAR HRS FROM TIME..........: 			
REGULAR HRS TO TIME............: 			
REGULAR WORK SCHEDULE..........: 			
DATE OF INJURY.................: 			
DATE NOTICE RECEIVED...........: 			
DATE/TIME STOPPED WORK.........: 			
DATE PAY STOPPED...............: 			
DATE 45 DAY PERIOD BEGAN.......: 			
DATE/TIME RETURNED TO WORK.....: 			
INJURED PERFORMING DUTY........: 			
NOT INJURED PERFORMING JOB.....: 			
INJURY CAUSED BY EMPLOYEE......: 			
CAUSED BY EMPLOYEE EXPLAIN.....: 			
INJURY CAUSED BY 3RD PARTY.....: 			
3RD PARTY NAME.................: 			
3RD PARTY ADDRESS..............: 			
3RD PARTY CITY.................: 			
3RD PARTY STATE................: 			
3RD PARTY ZIP CODE.............: 			
PROVIDING PHYSICAN NAME........: 			
PROVIDING PHYSICIAN ADDRESS....: 			
PROVIDING PHYSICIAN CITY.......: 			
PROVIDING PHYSICIAN STATE......: 			
PROVIDING PHYSICIAN ZIP CODE...: 			
PROVIDING PHYSICIAN TITLE......: 			
FIRST DATE OF MEDICAL CARE.....: 			
DISABLED FOR WORK..............: 			
SUPERVISOR AGREE/DISAGREE......: 			
SUPERVISOR NOT AGREE EXPLAIN...: 			
REASON FOR CONTROVERTS COP.....: 			
PAY RATE WHEN WORK STOPPED.....: 			
SUPERVISOR EXCEPTION...........: 			
NAME OF SUPERVISOR.............: 			
SUPERVISOR'S DATE OF SIGNATURE.: 			
SUPERVISOR'S TITLE.............: 			
SUPERVISOR'S OFFICE PHONE......: 			
FILING INSTRUCTIONS............: 			
Case # 			
ILLNESS OCCURRED (LOCATION)....: 			
ILLNESS OCCURRED ADDRESS.......: 			
ILLNESS OCCURRED CITY..........: 			
ILLNESS OCCURRED STATE.........: 			
ILLNESS OCCURRED ZIP CODE......: 			
DATE FIRST AWARE OF ILLNESS....: 			
DATE FIRST REALIZED CAUSE.......: 			
RELATIONSHIP OF ILLNESS TO EMP.: 			
NATURE OF DISEASE/ILLNESS......: 			
REASON CLAIM NOT FILED.........: 			
EMPLOYEE STATEMENT DELAY.......: 			
REASON MEDICAL REPORT DELAYED..: 			
DATE OF EMPLOYEE SIGNATURE.....: 			
1ST PROVIDING PHYSICAN NAME....: 			
1ST PROVIDING PHYS. ADDRESS....: 			
1ST PROVIDING PHYS. CITY.......: 			
1ST PROVIDING PHYS. STATE......: 			
1ST PROVIDING PHYS. ZIP CODE...: 			
1ST PROVIDING PHYS. TITLE......: 			
DATE 1ST REPORTED TO SUPERVISOR: 			
DATE/TIME WORK STOPPED.........: 			
DATE OF LAST EXPOSURE..........: 			
WORK DUTY CHANGED..............: 			
EMP RETIREMENT COVERAGE DESC.: 			
 Case number 			
 will be assigned to this incident.			
2 PERSONNEL STATUS.........			
 PERSON INVOLVED..........: 			
No SSN on file in the New Person file. Must enter to create case.			
This person (SSN) is a 'PAID' Employee, Please Re-enter			
1 PERSON INVOLVED..........			
Social Security Number is Required			
Date of Birth is required			
Sex is Required			
8 HOME STREET ADDRESS......			
Invalid character entered, (~,`,@,#,$,%,*,_,|,\,},{,[,],>, or <),			
please edit.			
11 ZIP CODE.................			
12 HOME PHONE NUMBER........			
Phone number must include area code and 7 digits only.  Example 703-123-8789			
13 STATION NUMBER...........//^S X=STN			
4 DATE/TIME INJURY OCCURRED			
4 DATE 1ST AWARE OF ILLNESS			
3 TYPE OF INCIDENT.........			
 VOLUNTARY SVC SUPERVISOR.			
 CONTRACT ADMINISTRATOR...			
 SAFETY OFFICER...........			
53.1 SECONDARY SUPERVISOR.....			
This Case will be DELETED!			
 Case action			
 has been saved.			
The following case(s) are Open with SSN: 			
CASE NUMBER: 			
PERSON INVOLVED: 			
PERSONNEL STATUS:			
PAY PLAN: 			
TYPE OF INCIDENT: 			
DATE/TIME OF OCCURRENCE: 			
INJURY/ILLNESS: 			
SUPERVISOR: 			
PERSON ENTERING STUB RECORD: 			
 Is the Current entry a DUPLICATE Case: 			
 VOLUNTARY SVC SUP......: 			
 CONTRACT ADMINISTRATOR.: 			
 SAFETY OFFICER.........: 			
 CASE NUMBER............: 			
 PERSONNEL STATUS.......: 			
 TYPE OF INCIDENT.......: 			
 CASE STATUS............: 			
 PERSON INVOLVED........: 			
 DATE OF BIRTH..........: 			
 HOME ADDRESS...........: 			
 HOME PHONE NUMBER......: 			
 STATION NUMBER.........: 			
 COST CENTER/ORG........: 			
 SECONDARY SUPERVISOR...: 			
 DATE/TIME OF OCCURRENCE: 			
Print Employee Bill of Rights			
EMPLOYEES' BILL OF RIGHTS FOR ACCIDENT AND OCCUPATIONAL ILLNESSES			
The Federal Employees' Compensation Act (FECA) describes an employee's			
rights and entitlements to benefits following a work-related			
injury or illness.			
You have the right to file a CA-1 (injury) or CA-2 (illness), to apply			
for compensation.			
Entitlements include the option to receive medical treatment by either			
the VA Employee Health Unit or by your primary care physician.			
You have the right to request union representation.			
For additional information and explanation of your rights and			
responsibilities, contact your Workers' Compensation			
Specialist/Coordinator/Manager.			
You have the right to select the physician or facility to provide			
treatment for the sustained injury or illness.  The VA facility is			
available for examination and treatment, but cannot mandate use of			
the facility to the exclusion of your choice of medical care.			
apply for compensation.			
You have the right to union representation at any time.			
OOPS DOL XMIT DATA			
You do not have the required Security Key.			
 Press Enter to continue			
Domain not found in the DOMAIN File,			
 No Transmission.  Press Enter to continue			
Re-transmit cases for what date 			
Enter the date of original transmission for cases 			
that need to be resent			
Enter 'Y' if you want the CA1/CA2 data placed in mail			
message as part of a tasked job.			
TRANSMIT DOL CA1/CA2 DATA			
Transmission NOT queued, OK to continue			
The Queue Q-AST.MED.VA.GOV has not been created.  Please contact your IRM 			
Dept. to have Patch XM*999*136 installed; once installed complete manual 			
transmission of DOL Data.			
OOPS WC MESSAGE			
The Mail Group OOPS WC MESSAGE is missing.			
Add the Group so that ASISTS data can be transmitted 			
to the AAC.  Then contact Worker Compensation office 			
to complete manual Transmission of DOL Data.			
There are no members of the OOPS WC MESSAGE 			
Mail Group.			
Enter at least one member to the group.  This person 			
will receive messages concerning the transmission of 			
ASISTS DOL data to and from the AAC. After adding member			
contact Worker Compensation office to complete manual transmission of DOL data.			
No cases to transmit for requested date			
ASISTS Report on Daily Transmission to the AAC			
ASISTS no claims to process			
There were no claims ready for transmission			
to the Austin Automation Center when the.			
scheduled task last ran.			
Mail Message was not created.  Contact Worker Compensation office 			
to complete the transmission of ASISTS DOL data.			
ASISTS DOL DATA			
XXX@Q-AST.MED.VA.GOV			
Case: 			
 has missing required data or word processing fields that are			
larger than DOL requirements.  Please edit the case(s); and once completed,			
the cases will be transmitted with the next scheduled transmission. 			
ASISTS Record(s) not transmitted for Station 			
OOPS WCP			
The following claims have been transmitted to the AAC:			
ASISTS Record(s) transmitted to AAC for Station 			
ASISTS Package			
ASISTS DOL Error Notification Message			
An Error Occurred during Processing, check			
Mailman Message for details.			
PRINT CA FORM			
No SSN on file for this Employee			
An Accident Report has not been created for this Employee			
   Select Case: 			
Claim cannot be signed until the Bill of Rights Statement is understood.			
Checking for Safety and Emp Health Ok to sign for Employee.			
Please enter a Signature Code.			
71I have read and understood the Employee Bill of Rights:			
 Notice of Occupational Disease and Claim for Compensation (Form CA-2)			
     Employee Data			
  1. NAME OF EMPLOYEE......: 			
  2. SOCIAL SECURITY NUMBER: 			
  3. DATE OF BIRTH.........: 			
12  5. HOME TELEPHONE........			
  7. EMPLOYEE'S HOME MAILING ADDRESS:			
8     STREET ADDRESS........			
11     ZIP CODE..............			
     Claim Information			
 10. LOCATION WHERE YOU WORKED WHEN DISEASE OR ILLNESS OCCURRED:			
210     STREET ADDRESS........			
213     ZIP CODE..............			
214 11. DATE YOU FIRST BECAME AWARE OF DISEASE OR ILLNESS;I X=			
215 12. DATE YOU FIRST REALIZED THE DISEASE OR ILLNESS WAS CAUSED BY YOUR               EMPLOYMENT;I X=			
216 13. EXPLAIN THE RELATIONSHIP TO YOUR EMPLOYMENT, AND WHY YOU CAME TO THIS           REALIZATION~			
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