English	French	Notes	Complete/Exclude
PU14.1,18.8;PD16.7,18.8;PU14.1,18.8;PD14.1,19;PU14.9,18.8;PD14.9,19;PU15.8,18.8;PD15.8,19;PU16.7,18.8;PD16.7,19;PU.5,18.4;PD21,18.4;			
PU.5,18.4;PD21,18.4;PU.5,18.1;LB30. Date@;PU2.6,18.1;LBMo.@;PU3.5,18.1;LBDay@;PU4.5,18.1;LBYr.#			
PU1.1,17.8;LBreturned@;PU1.1,17.5;LBto work@;PU2.5,17.5;PD5.1,17.5;PU2.5,17.5;PD2.5,17.7;PU3.3,17.5;PD3.3,17.7;PU4.2,17.5;PD4.2,17.7;			
PU5.1,17.5;PD5.1,17.7;PU5.4,17.5;LBTime@;SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.9,17.5;LB:@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU7.8,17.7;EA8,17.9;PU8.2,17.7;LBa.m.@;PU7.8,17.3;EA8,17.5;PU8.2,17.3;LBp.m.@;			
PU.5,17.1;PD21,17.1;PU.5,16.8;LB31. If employee has returned to work and work assignment has changed, describe new duties@;			
PU.5,12.6;PD21,12.6;			
PU.5,12.3;LB32. Was injury caused@;PU3.6,12.6;PD3.6,10.1;PU3.6,11.7;PD21,11.7;PU3.6,10.9;PD21,10.9;			
PU3.7,12.3;LB33. Name and address of third party (Include city, state, and zip code)@;			
PU.9,12;LBby third party?@;PU.9,11.5;EA1.1,11.7;PU1.3,11.5;LBYes@;PU2.3,11.5;EA2.5,11.7;PU2.7,11.5;LBNo@;			
PU2.3,11.2;LBIf 			
No,			
@;PU2.3,10.9;LBgo to@;PU2.3,10.6;LBitem 34.@;			
PU.5,10.1;PD21,10.1;PU.5,9.6;PD21,9.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.7;LBSignature of Supervisor@;PU.5,9.6;RA21,10.1;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9.3;LB34. A supervisor who knowingly certifies to any false statement,@;			
LB misrepresentation, concealment of fact, etc., in respect to this claim@;			
PU1.1,8.9;LBmay also be subject to appropriate felony criminal prosecution.@;			
PU1.1,8.4;LBI certify that the information given above and that furnished by the employee on the reverse@;			
LB of this form is true to the best of my@;			
PU1.1,8.1;LBknowledge with the following exception:@;			
PU.5,6.2;PD21,6.2;PU.5,5.9;LBName of Supervisor (Type or print)@;			
PU.5,5.4;PD21,5.4;PU.5,5.1;LB Signature of Supervisor@;PU12.4,5.1;LBDate@;			
PU.5,4.6;PD21,4.6;PU.5,4.3;LBSupervisor's Title@;PU12.4,4.3;LBOffice phone@;			
PU.5,3;PD21,3;PU19,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBCA-2@;			
SD1,277,2,1,4,12,5,0,6,0,7,16901;PU1,28.6;LBFederal Employee's Notice of#;PU1,28.2;LBTraumatic Injury and Claim for#;			
PU1,27.8;LBContinuation of Pay/Compensation#;			
SD1,277,2,1,4,12,5,0,6,1,7,23;PU11,28.5;LBU.S. Department of Labor#;			
SD1,277,2,1,4,10,5,0,6,0,7,16901;PU11,28.1;LBEmployment Standards Administration#;			
PU11,27.8;LBOffice of Workers' Compensation Programs#;			
PU1,27.6;PD21,27.6;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,27.3;LBEmployee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.#			
PU1,26.9;LBWitness: Complete bottom section 16.#;			
PU1,26.5;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.#;			
PU.9,26;FT10,10;RA21,26.4;EA21,26.4;PU1,26.1;LBEmployee Data#;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,25.7;LB1. Name of employee (Last, First, Middle)#;			
PU16.5,25.7;LB2. Social Security Number#;PU1,25.2;PD21,25.2;PU16.4,26;PD16.4,25.2;			
PU1,24.9;LB3. Date of birth#;PU3.4,24.9;LBMo.#;PU4.3,24.9;LBDay#;PU5.3,24.9;LBYr.#;			
PU6.8,24.4;PD6.8,25.2;PU6.9,24.9;LB4. Sex#;PU10.2,25.2;PD10.2,24.4;PU10.3,24.9;LB5. Home telephone#;			
PU15,25.2;PD15,24.4;PU15.1,24.9;LB6. Grade as of#;			
PU3.3,24.5;PD5.9,24.5;PU3.3,24.5;PD3.3,24.7;PU4.1,24.5;PD4.1,24.7;PU5,24.5;PD5,24.7;PU5.9,24.5;PD5.9,24.7;			
PU7.2,24.5;EA7.4,24.7;PU7.6,24.5;LBMale#;PU8.6,24.5;EA8.8,24.7;PU9,24.5;LBFemale#;			
PU15.5,24.6;LBdate of injury#;			
PU17.5,24.6;LBLevel#;PU19.1,24.6;LBStep#;			
PU1,24.4;PD21,24.4;			
PU1,24.1;LB7. Employee's home mailing address (Include city, state, and ZIP code)#;PU1,23.4;PD16.4,23.4;			
PU16.5,24.1;LB8. Dependents#;PU16.9,23.6;EA17.1,23.8;PU17.3,23.6;LBWife, Husband#;			
PU16.9,23.2;EA17.1,23.4;PU17.3,23.2;LBChildren under 18 years#;			
PU16.9,22.8;EA17.1,23;PU17.3,22.8;LBOther#;			
PU1,23.4;PD16.4;PU16.4,24.4;PD16.4,22.4;			
PU.9,22;RA21,22.4;EA21,22.4;PU1,22.1;SD1,277,2,1,4,9,5,0,6,1,7,23;LBDescription of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU1,21.7;LB9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)#;			
PU1,20.8;PD21,20.8;PU1,20.5;LB10. Date injury occurred#;PU4.6,19.6;PD4.6,20.8;PU7.7,19.6,PD7.7,20.8;PU11.2,19.6;PD11.2,20.8;			
PU4.7,20.5;LBTime#;PU7.8,20.5;LB11. Date of this notice#;PU11.3,20.5;LB12. Employee's occupation#;			
PU1.2,19.7;PD3.9,19.7;PU1.2,19.7;PD1.2,19.9;PU2.1,19.7;PD2.1,19.9;PU3,19.7;PD3,19.9;PU3.9,19.7;PD3.9,19.9;			
PU1.3,20.1;LBMo.#;PU2.2,20.1;LBDay#;PU3.1,20.1;LBYr.#;SD1,277,2,1,4,9,5,0,6,3,7,23;PU5.5,20;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU6.5,20.1;EA6.7,20.3;PU6.9,20.1;LBa.m.#;PU6.5,19.7;EA6.7,19.9;PU6.9,19.7;LBp.m.#;			
PU8.1,19.7;PD10.8,19.7;PU8.1,19.7;PD8.1,19.9;PU9,19.7;PD9,19.9;PU9.8,19.7;PD9.8,19.9;PU10.8,19.7;PD10.8,19.9;			
PU8.2,20.1;LBMo.#;PU9.1,20.1;LBDay#;PU9.9,20.1;LBYr.#;			
PU1,19.6;PD21,19.6;PU1,18.6;PD21,18.6;PU1,17.6;PD21,17.6;PU1,16.6;PD21,16.6;			
PW.5;PU16.3,18.6;RA21,15.6;EA21,15.6;PW.3;			
PU16.4,18.3;LBa. Occupation code#;PU16.4,17.3;LBb. Type code#;PU18.4,17.6;PD18.4,16.6;PU18.5,17.3;LBc. Source code#;			
PU16.4,16.3;LBOWCP Use - NOI Code#;			
PU1,19.3;LB13. Cause of injury (Describe what happened and why)#;			
PU1,17.3;LB14. Nature of injury (Identify both the injury and the part of body, e.g., fracture of left leg)#;			
PU.9,15.2;RA21,15.6;EA21,15.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,15.3;LBEmployee Signature#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU1,14.9;LB15. I certify, under penalty of law, that the injury described above#;			
LB was sustained in performance of duty as an employee of the#;			
PU1.5,14.6;LBUnited States Government and that it was not caused by my willful misconduct#;			
LB, intent to injure myself or another person, nor by#;			
PU1.5,14.3;LBmy intoxication. I hereby claim medical treatment, if needed, and the following,#;			
LB as checked below, while disabled for work:#;			
PU1.5,13.5;EA1.7,13.7;PU1.9,13.5;LBa. Continuation of regular pay (COP) not to exceed 45#;			
LB days and compensation for wage loss if disability for work continues#;			
PU2.3,13.2;LBbeyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick#;			
PU2.3,12.9;LBor annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.#;			
PU1.5,12.4;EA1.7,12.6;PU1.9,12.4;LBb. Sick and/or Annual Leave#;			
PU1.7,11.9;LBI hereby authorize any physician or hospital (or any other person, institution,#;			
LB corporation, or government agency) to furnish any#;			
PU1.7,11.6;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation#;			
LB Programs (or to its official representative).#;			
PU1.7,11.3;LBThis authorization also permits any official representative of the Office#;			
LB to examine and to copy any records concerning me.#;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,10.6;LBSignature of employee or person acting on his/her behalf#;PU9.3,10.6;PD21,10.6;			
PU16.8,10.7;LBDate#;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,10.1;LBAny person who knowingly makes any false statement,#;			
LB misrepresentation, concealment of fact or any other act of fraud to obtain compensation#;			
PU1,9.8;LBas provided by the FECA or who knowingly accepts compensation to which that person is not#;			
LB entitled is subject to civil or administrative#;			
PU1,9.5;LBremedies as well as felony criminal prosecution and may, under appropriate criminal provisions,#;			
LB be punished by a fine or imprisonment or both.#;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,8.9;LBHave your supervisor complete the receipt attached to this form#;			
LB and return it to you for your records.#;			
PU.9,8.2;RA21,8.6;EA21,8.6;PU1,8.3;LBWitness Statement#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU1,7.9;LB16. Statement of witness (Describe what you saw, heard, or know about this injury)#;			
PU1,4.6;PD21,4.6;PU1,4.3;LBName of witness#;			
PU8.9,4.3;LBSignature of witness#;PU17.6,4.3;LBDate signed#;			
PU1,3.8;PD21,3.8;PU1,3.5;LBAddress#;PU8.9,3.5;LBCity#;PU13.6,3.5;LBState#;PU17.6,3.5;LBZIP Code#;			
PU1,3;PD21,3;PU17.5,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBForm CA-1#;PU17.5,2.1;LBRev. Apr. 1999#;			
PU1.3,25.4,LB			
PU16.8,25.3;LB			
PU7.2,24.5;LBX#;			
PU8.6,24.5;LBX#;			
PU10.8,24.6;LB			
PU18.4,24.6;LB			
PU1.3,23.6;LB			
PU1.3,22.6;LB			
LB, 			
PU16.9,23.6;LBX#;			
PU16.9,23.2;LBX#;			
PU16.9,22.8;LBX#;			
PU16.9,23.6;LBX#;PU16.9,23.2;LBX#;			
PU16.9,23.6;LBX#;PU16.9,22.8;LBX#;			
PU16.9,23.2;LBX#;PU16.9,22.8;LBX#;			
PU16.9,23.6;LBX#;PU16.9,23.2;LBX#;PU16.9,22.8;LBX#;			
PU1.3,21;LB			
PU11.6,20;LB			
PU1.3,18.8;LB			
PU1.3,18.2;LB			
PU1.3,17.8;LB			
PU17.4,17.8;LB			
PU1.3,16.8;LB			
PU16.8,16.8;LB			
PU18.9,16.8;LB			
PU1.3,15.8;LB			
PU16.8,15.8;LB			
PU1.5,13.5;LBX#;			
PU1.5,12.4;LBX#;			
PU9.6,10.7;LB/ES/ 			
PU17.6,10.7;LB			
PU1.5,7.0;LB			
PU1.5,3.9;LB			
PU17.9,3.9;LB			
PU1.5,3.2;LB			
PU8.2,3.2;LB			
PU13.4,3.2;LB			
PU17.9,3.2;LB			
PU1,3.9;LB			
DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;			
PU.5,28.8;LBOfficial Supervisor's Report: Please complete information requested below:#;			
PU.4,28.2;FT10,10;RA21,28.6;EA21,28.6;PU.5,28.3;LBSupervisor's Report#;			
PU.5,27.9;LB17. Agency name and address of reporting office (Include city, state, and ZIP code)#;			
PU17,28.2;PD17,27.3;PU17.1,27.9;LBOWCP Agency Code#;			
PU15.7,26.4;PD15.7,27.3;PU15.8,27;LBOSHA Site Code#;PU14.5,26.1;LBZIP Code#;			
PU.5,26.1;LB18. Employee's duty station (Street address and ZIP code)#;			
PU.5,25.3;LB19. Employee's retirement coverage#;			
PU7.2,25.3;EA7.4,25.1;PU7.8,25.1;LBCSRS#			
PU9.2,25.3;EA9.4,25.1;PU9.8,25.1;LBFERS#			
PU11.2,25.3;EA11.4,25.1;PU11.8,25.1;LBOther, (Identify)#			
PU.5,24.4;LB20. Regular#;PU1,24;LBwork#;PU1,23.6;LBhours#;PU2.2,23.6;LBFrom#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU3.4,23.6;LB:#;			
PU4.1,24.2;EA4.3,24.4;PU4.5,24.2;LBa.m.#;PU4.1,23.7;EA4.3,23.9;PU4.5,23.7;LBp.m.#;PU5.8,23.6;LBTo#;			
SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.8,23.6;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU7.4,24.2;EA7.6,24.4;PU7.8,24.2;LBa.m.#;PU7.4,23.7;EA7.6,23.9;PU7.8,23.7;LBp.m.#;			
PU8.9,24.7;PD8.9,23.4;PU9,24.4;LB21. Regular#;PU9.6,24;LBwork#;PU9.6,23.6;LBschedule#;			
PU11,23.6;EA11.2,23.8;PU11.4,23.6;LBSun.#;PU12.3,23.6;EA12.5,23.8;PU12.7,23.6;LBMon.#;			
PU13.6,23.6;EA13.8,23.8;PU14,23.6;LBTues.#;PU14.9,23.6;EA15.1,23.8;PU15.3,23.6;LBWed.#;			
PU16.2,23.6;EA16.4,23.8;PU16.6,23.6;LBThurs.#;PU17.7,23.6;EA17.9,23.8;PU18.1,23.6;LBFri.#;			
PU18.8,23.6;EA19,23.8;PU19.2,23.6;LBSat.#;			
PU.5,23.4;PD21,23.4;PU.5,23.1;LB22. Date#;PU2.5,23.1;LBMo.#;PU3.5,23.1;LBDay#;PU4.5,23.1;LBYr.#;			
PU5.6,23.4;PD5.6,22.4;PU5.7,23.1;LB23. Date#;PU8,23.1;LBMo.#;PU9,23.1;LBDay#;PU10,23.1;LBYr.#;			
PU11,23.4;PD11,22.4;PU11.1,23.1;LB24. Date#;PU13.2,23.1;LBMo.#;PU14.2,23.1;LBDay#;PU15.2,23.1;LBYr.#;			
PU1,22.8;LBof#;PU6.2,22.8;LBnotice#;PU11.6,22.8;LBstopped#;			
PU1,22.5;LBinjury#;PU2.2,22.5;PD5.2,22.5;PU2.2,22.5;PD2.2,22.7;PU3.2,22.5;PD3.2,22.7;PU4.2,22.5;PD4.2,22.7;PU5.2,22.5;PD5.2,22.7;			
PU6.2,22.5;LBreceived#;PU7.7,22.5;PD10.5,22.5;PU7.7,22.5;PD7.7,22.7;PU8.7,22.5;PD8.7,22.7;			
PU9.7,22.5;PD9.7,22.7;PU10.5,22.5;PD10.5,22.7;			
PU11.6,22.5;LBwork#;PU12.9,22.5;PD15.7,22.5;PU12.9,22.5;PD12.9,22.7;PU13.9,22.5;PD13.9,22.7;			
PU14.8,22.5;PD14.8,22.7;PU15.7,22.5;PD15.7,22.7;			
PU16,22.5;LBTime#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU17.2,22.5;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU17.8,23;EA18,23.2;PU18.2,23;LBa.m.#;PU17.8,22.5;EA18,22.7;PU18.2,22.5;LBp.m.#;			
PU.5,22.4;PD21,22.4;			
PU.5,22.1;LB25.Date#;PU2.5,22.1;LBMo.#;PU3.5,22.1;LBDay#;PU4.5,22.1;LBYr.#;PU5.5,22.4;PD5.5,21.3;PU5.6,22.1;LB26.Date#;			
PU6.1,21.8;LB45 day#;			
PU8.4,22.1;LBMo.#;PU9.3,22.1;LBDay#;PU10.3,22.1;LBYr.#;PU11.3,22.4;PD11.3,21.3;PU11.4,22.1;LB27.Date#;			
PU13.4,22.1;LBMo.#;PU14.4,22.1;LBDay#;PU15.4,22.1;LBYr.#;			
PU1,21.8;LBpay#;PU1,21.5;LBstopped#;PU2.2,21.5;PD5.2,21.5;PU2.2,21.5;PD2.2,21.7;PU3.2,21.5;PD3.2,21.7;			
PU4.2,21.5;PD4.2,21.7;			
PU5.2,21.5;PD5.2,21.7;			
PU6.1,21.5;LBperiod began#;PU8.2,21.5;PD11,21.5;PU8.2,21.5;PD8.2,21.7;PU9.1,21.5;PD9.1,21.7;			
PU10.1,21.5;PD10.1,21.7;PU11,21.5;PD11,21.7;			
PU11.9,21.8;LBreturned#;PU11.9,21.5;LBto work#;PU13.2,21.5;PD16,21.5;PU13.2,21.5;PD13.2,21.7;			
PU14.2,21.5;PD14.2,21.7;PU15.2,21.5;PD15.2,21.7;			
PU16,21.5;PD16,21.7;PU16.3,21.5;LBTime#;SD1,277,2,1,4,9,5,0,6,5,7,23;PU17.5,21.5;LB:#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU18.2,21.9;EA18.4,22.1;PU18.6,21.9;LBa.m.#;PU18.2,21.5;EA18.4,21.7;PU18.6,21.5;LBp.m.#;			
PU.5,21.3;PD21,21.3;			
PU.5,21;LB28. Was employee injured in performance of duty?#			
PU7.6,21;EA7.8,21.2;PU8,21;LBYes#;PU9,21;EA9.2,21.2;PU9.4,21;LBNo#;PU10,21;LB(If 			
PU.5,19.8;PD21,19.8;PU.5,19.5;LB29. Was injury caused by employee's willful misconduct, intoxication,#;			
LB or intent to injure self or another?#;			
PU15,19.5;EA15.2,19.7;PU15.4,19.5;LBYes#;PU16.2,19.5;LB(If 			
Yes,			
PU19.2,19.5;EA19.4,19.7;PU19.6,19.5;LBNo#;			
PU.5,18.4;PD21,18.4;PU.5,18.1;LB30. Was injury caused#;PU4.2,18.4;PD4.2,15.8;PU4.2,17.6;PD21,17.6;PU4.2,16.7;PD21,16.7;			
PU4.3,18.1;LB31. Name and address of third party (Include city, state, and ZIP code)#;			
PU1,17.7;LBby third party?#;PU1,17.3;EA1.2,17.5;PU1.4,17.3;LBYes#;PU2.7,17.3;EA2.9,17.5;PU3.1,17.3;LBNo#;			
PU2.7,16.9;LB(If 			
#;PU2.7,16.5;LBgo to#;PU2.7,16.1;LBitem 32.)#;			
PU.5,15.8;PD21,15.8;PU.5,15.5;LB32. Name and address of physician first providing medical care#;			
LB (Include city, state, ZIP code)#;			
PU14.5,15.8;PD14.5,13.1;PU14.6,15.5;LB33. First date#;PU17.1,15.4;LBMo.#;PU18.1,15.4;LBDay#;PU19.1,15.4;LBYr.#;			
PU15.1,15.2;LBmedical care#;PU15.1,14.9;LBreceived#;PU14.5,14.6;PD21,14.6;			
PU16.8,14.8;PD19.6,14.8;PU16.8,14.8;PD16.8,15;PU17.8,14.8;PD17.8,15;PU18.7,14.8;PD18.7,15;PU19.6,14.8;PD19.6,15;			
PU14.6,14.3;LB34. Do medical#;PU15.1,14;LBreports show#;PU15.1,13.7;LBemployee is#;PU15.1,13.4;LBdisabled for work?#;			
PU17.4,14.1;EA17.6,14.3;PU17.8,14.1;LBYes#;PU18.8,14.1;EA19,14.3;PU19.2,14.1;LBNo#;			
PU.5,14.8;PD14.5,14.8;PU.5,13.9;PD14.5,13.9;PU.5,13.1;PD21,13.1;PU14.5,15.8;PU14.5,13.1;			
PU.5,12.8;LB35. Does your knowledge of the facts about this injury agree with statements#;			
LB of the employee and/or witness?#;			
PU15.8,12.7;EA16,12.9;PU16.2,12.7;LBYes#;PU17.1,12.7;EA17.3,12.9;PU17.5,12.7;LBNo (If 			
PU.5,11.3;PD21,11.3;PU.5,11;LB36. If the employing agency controverts continuation of pay, state the reason in detail.#;			
PU14.3,9.7;PD14.3,11.3;PU14.4,11;LB37. Pay rate#;PU15,10.7;LBwhen employee#;PU15,10.4;LBstopped work#;			
PU15,9.9;LB$#;PU17.9,9.9;LBPer#;			
PU.5,9.3;RA21,9.7;EA21,9.7;			
PU.5,9.2;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.4;LBSignature of Supervisor and Filing instructions#;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9;LB38. A supervisor who knowingly certifies to any false statement,#;			
PU1.1,8.6;LBmay also be subject to appropriate felony criminal prosecution.#;			
PU1.1,7.9;LBI certify that the information given above and that furnished by the employee on the reverse#;			
LB of this form is true to the best of my#;			
PU1.1,7.6;LBknowledge with the following exception:#;			
PU.5,6.8;PD21,6.8;PU.5,6.5;LBName of supervisor (Type or print)#;			
PU.5,6.1;PD21,6.1;PU.5,5.8;LB Signature of supervisor#;PU12.9,5.8;LBDate#;			
PU.5,5.3;PD21,5.3;PU.5,5;LBSupervisor's Title#;PU12.9,5;LBOffice phone#;			
PU.5,4.6;PD21,4.6;PU.5,4.3;LB39. Filing instructions#;			
PU4.7,3.9;EA4.9,4.1;PU5.1,4.3;LBNo lost time and no medical expense: Place this form in employee's medical folder (SF-66-D)#;			
PU4.7,4.3;EA4.9,4.5;PU5.1,3.9;LBNo lost time, medical expense incurred or expected: forward this form to OWCP#;			
PU4.7,3.5;EA4.9,3.7;PU5.1,3.5;LBLost time covered by leave, LWOP, or COP: forward this form to OWCP#;			
PU4.7,3.1;EA4.9,3.3;PU5.1,3.1;LBFirst Aid injury#;			
PU.5,3;PD21,3;PU17.5,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBForm CA-1#;PU17.5,2.1;LBRev. Apr. 1999#;			
PU1,27.4;LB			
PU17.7,27.4;LB			
PU1,26.6;LB			
PU1,25.7;LB			
PU7.2,25.1;LBX#;			
PU9.2,25.1;LBX#			
PU11.2,25.1;LBX#;			
PU1,24.8;LB			
PU3,23.6;LB			
PU4.1,24.2;LBX#;			
PU4.1,23.7;LBX#;			
PU6.3,23.6;LB			
PU7.4,24.2;LBX#;			
PU7.4,23.7;LBX#;			
PU7.6,21;LBX#;			
PU9,21;LBX#;			
PU1,20;LB			
PU15,19.5;LBX#;			
PU19.2,19.5;LBX#;			
PU1,18.6;LB			
PU1,17.3;LBX#;			
PU2.7,17.3;LBX#;			
PU4.3,17.7;LB			
PU4.3,16.8;LB			
PU4.3,15.9;LB			
PU1,15;LB			
PU1,14.1;LB			
PU1,13.3;LB			
PU17.4,14.1;LBX#;			
PU18.8,14.1;LBX#;			
PU15.8,12.7;LBX#;			
PU17.1,12.7;LBX#;			
PU1,12.4;LB			
PU1,12;LB			
PU1,11.6;LB			
PU1,12.3;LBSee Attached#;			
35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witness?			
PU1,10.6;LB			
PU1,10.2;LB			
PU1,9.8;1LB			
PU1,10.5;LBSee Attached#;			
36. If the employing agency controverts continuation of pay, state the reason in detail.			
PU15.2,9.9;LB			
PU1,7.1;LB			
PU1,6.2;LB			
PU1,5.4;LB/ES/ 			
PU12.9,5.4;LB			
PU1,4.7;LB			
PU4.7,4.3;LBX#;			
PU4.7,3.9;LBX#;			
PU4.7,3.5;LBX#;			
PU4.7,3.1;LBX#;			
DT#,1;SD1,277,2,1,4,9,5,0,6,1,7,23;FT10,10;PU.5,27.5;RA21,28;EA21,28;			
PU.6,27.6;LBBenefits for Employees under the Federal Employees' Compensation Act (FECA)#;			
PU.5,27;LBThe FECA, which is administered by the Office of Workers'#;			
PU.5,26.7;LBCompensation Programs (OWCP), provides the following#;			
PU.5,26.4;LBbenefits for job-related traumatic injuries:#;			
PU.5,25.5;LB(1) Continuation of pay for disability resulting from traumatic,#;			
PU1,25.2;LBjob-related injury, not to exceed 45 calendar days. (To be#;			
PU1,24.9;LBeligible for continuation of pay, the employee, or someone#;			
PU1,24.6;LBacting on his/her behalf, must file Form CA-1 within 30 days#;			
PU1,24.3;LBfollowing the injury and provide medical evidence in support#;			
PU1,24;LBof disability within 10 days of submission of the CA-1. Where#;			
PU1,23.7;LBthe employing agency continues the employee's pay, the pay#;			
PU1,23.4;LBmust not be interrupted unless one of the provision's outlined#;			
PU1,23.1;LBin 20 CFR 10.222 apply.#;			
PU.5,22.6;LB(2) Payment of compensation for wage loss after the expiration#;			
PU1,22.3;LBof COP, if disability extends beyond such point, or if COP is not#;			
PU1,22.0;LBpayable. If disability continues after COP expires, Form CA-7,#;			
PU1,21.7;LBwith supporting medical evidence, must be filed with OWCP.#;			
PU1,21.4;LBto avoid interruption of income, the form should be filed on the#;			
PU1,21.1;LB40th day of the COP period.#;			
PU.5,20.6;LB(3) Payment of compensation for permanent impairment of#;			
PU1,20.3;LBcertain organs, members, or functions of the body (such as#;			
PU1,20.0;LBloss or loss of use of an arm or kidney, loss of vision, etc.),#;			
PU1,19.7;LBor for serious disfigurement of the head, face, or neck.#;			
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