English	French	Notes	Complete/Exclude
PU10.9,25.5;LB(4) Vocational rehabilitation and related services where#;			
PU11.4,25.2;LBdirected by OWCP.#;			
PU10.9,24.1;LB(5) All necessary medical care from qualified medical providers.#;			
PU11.4,23.8;LBThe injured employee may choose the physician who provides#;			
PU11.4,23.5;LBinitial medical care. Generally, 25 miles from the place of#;			
PU11.4,23.2;LBinjury, place of employment, or employee's home is a reasonable#;			
PU11.4,22.9;LBdistance to travel for medical care.#;			
PU11.4,22.2;LBAn employee may use sick or annual leave rather than LWOP#;			
PU11.4,21.9;LBwhile disabled. The employee may repurchase leave used#;			
PU11.4,21.6;LBfor approved periods. Form CA-7b, available from the#;			
PU11.4,21.3;LBpersonnel office, should be studied BEFORE a decision#;			
PU11.4,21.0;LBis made to use leave.#;			
PU11.4,20.3;LBFor additional information, review the regulations governing#;			
PU11.4,20.0;LBthe administration of the FECA (Code of Federal Regulations,#;			
PU11.4,19.7;LBChapter 20, Part 10) or pamphlet CA-810.#;			
PU.5,18.4;EA21,18.9;RA21,18.9;PU.6,18.5;SD1,277,2,1,4,9,5,0,6,1,7,23;LBPrivacy Act#;			
PU.5,18.0;LBIn accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'#;			
PU.5,17.5;LBCompensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation#;			
PU.5,17.0;LBPrograms of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)#;			
PU.5,16.5;LBInformation which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be#;			
PU.5,16.0;LBverified through computer matches or other appropriate means. (3) Information may be given to the Federal Agency which employed the#;			
PU.5,15.5;LBclaimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to#;			
PU.5,15.0;LBconsider issues relating to retention, rehire, or relevant matters. (4) Information may also be given to other Federal agencies, other#;			
PU.5,14.5;LBgovernment entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. #;			
PU.5,14.0;LB(5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational#;			
PU.5,13.5;LBrehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be#;			
PU.5,13.0;LBgiven to the Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to#;			
PU.5,12.5;LBdetermine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to#;			
PU.5,12.0;LBpursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7)#;			
PU.5,11.5;LBDisclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and#;			
PU.5,11.0;LBother information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal#;			
PU.5,10.5;LBGovernment, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing#;			
PU.5,10.0;LBof the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.#;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.5;LBNote: This notice applies to all forms requesting information that you might receive from the Office in connection with the#;			
PU.5,9.0;LBprocessing and adjudication of the claim you filed under the FECA. #;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU.6,8;LBReceipt of Notice of Injury#;PU.5,7.9;RA21,8.4;EA21,8.4;			
PU.5,7.5;LBThis acknowledges receipt of notice of injury sustained by:#;			
PU.5,7.2;LB(Name of injured employee)#;			
PU.5,6.3;PD21,6.3;PU.5,6;LBWhich occurred on (Mo., Day, Yr.)#;			
PU.5,5.5;PD21,5.5:PU.5,5.2;LBAt (Location)#;			
PU.5,4.2;PD21,4.2;PU.5,3.9;LBSignature of Official Superior#;			
PU9.4,3.9;LBTitle#;PU16.3,3.9;LBDate (Mo., Day, Yr.)#;			
DT@,1;			
SD1,277,2,1,4,12,5,0,6,0,7,16901;PU.4,28.7;LBNotice of Occupational Disease@;			
PU.4,28.2;LBand Claim for Compensation@;			
SD1,277,2,1,4,12,5,0,6,1,7,23;PU10.5,28.7;LBU.S. Department of Labor@;			
SD1,277,2,1,4,10,5,0,6,0,7,16901;PU10.5,28.2;LBEmployment Standards Administration@;			
PU10.5,27.9;LBOffice of Workers' Compensation Programs@;			
PU.4,27.7;PD21,27.7;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,27.3;LBEmployee: Please complete all boxes 1 - 18 below. Do not complete shaded areas.@;			
PU.4,26.9;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.@;			
PU.4,26.7;PD21,26.7;PU.4,26.3;FT10,10;RA21,26.7;PU.4,26.4;LBEmployee Data@;PU.4,26.3;PD21,26.3;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.4,26;LB1. Name of employee (Last, First, Middle)@;			
PU15.7,26.3;PD15.7,25.4;PU15.8,26;LB2. Social Security Number@;PU.4,25.4;PD21,25.4;			
PU.4,25.1;LB3. Date of birth@;PU3,25.1;LBMo.@;PU3.9,25.1;LBDay@;PU4.9,25.1;LBYr.@;			
PU6.3,24.6;PD6.3,25.4;PU6.4,25.1;LB4. Sex@;PU8,25.4;PD8,24.6;PU8.1,25.1;LB5. Home telephone@;			
PU12.4,25.4;PD12.4,24.6;PU12.5,25.1;LB6. Grade as of date@;			
PU2.9,24.7;PD5.4,24.7;PU2.9,24.7;PD2.9,24.9;PU3.7,24.7;PD3.7,24.9;PU4.7,24.7;PD4.7,24.9;PU5.4,24.7;PD5.4,24.9;			
PU13,24.7;LBof last exposure@;PU15.6,24.7;LBLevel@;PU17.9,24.7;LBStep@;			
PU.4,24.6;PD21,24.6;PU.4,24.3;LB7. Employee's home mailing address (Include city, state, and zip code)@;			
PU15.9,24.3;LB8. Dependents@;PU16.2,23.8;EA16.4,24;PU16.6,23.8;LBWife, Husband@;			
PU16.2,23.4,EA16.4,23.6;PU16.6,23.4;LBChildren under 18 years@;			
PU16.2,23;EA16.4,23.2;PU16.6,23;LBOther@;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU15.8,21.7;LBa. Occupation code@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.4,22.5;PD21,22.5;PU15.8,24.6;PD15.8,22.5;			
PU.4,22;PD21,22;PU.4,22.1;SD1,277,2,1,4,9,5,0,6,1,7,23;LBClaim Information@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.4,22;RA21,22.5;PU.4,21.7;LB9. Employee's occupation@;PU.4,20.7;PD21,20.7;			
PU.4,20.4;LB10. Location (address) where you worked when disease or illness occurred (Include city, state, and zip code)@;			
PU15.8,20.4;LB11. Date you first became@;PU16.3,20.1;LBaware of disease@;			
PU16.3,19.7;LBor illness@;PU16.3,19.3;LBMo.@;PU17.3,19.3;LBDay@;PU18.3,19.3;LBYr.@;			
PU16.3,18.7;PD18.7,18.7;PU16.3,18.7;PD16.3,18.9;PU17.1,18.7;PD17.1,18.9;PU18,18.7;PD18,18.9;PU18.7,18.7;PD18.7,18.9;			
PU.4,18.6;PD15.7,18.6;EA21,22;PU15.7,20.7;RA21,22;			
PU.4,18.3;LB12. Date you first realized@;PU.9,18;LBthe disease or illness@;PU4.8,18;LBMo.@;PU5.7,18;LBDay@;			
PU6.7,18;LBYr.@;PU.9,17.7;LBwas caused or aggravated@;PU.9,17.4;LBby your employment@;			
PU4.7,17.4;PD7.3,17.4;PU4.7,17.4;PD4.7,17.6;PU5.6,17.4;PD5.6,17.6;PU6.4,17.4;PD6.4,17.6;PU7.3,17.4;PD7.3,17.6;			
PU7.4,18.6;PD7.4,17.3;PD.5,17.3;PU7.5,18.3;LB13. Explain the relationship@;			
LB to your employment, and why you came to this realization@;			
PU.4,14.5;PD15.7,14.5;PU15.7,13.8;EA21,14.5;PU15.7,12.8;EA17.9,13.8;RA21,14.5;PU17.9,12.8;EA21,13.8;			
PU.4,14.2;LB14. Nature of disease or illness@;PU15.8,14.2;SD1,277,2,1,4,9,5,0,6,1,7,23;LBOWCP Use - NOI Code@;			
PU15.8,13.5;LBb. Type code@;PU18,13.5;LBc. Source code@;PU.4,12.8;PD15.7,12.8;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.4,12.5;LB15. If this notice and claim was not filed with the employing agency within 30 days after date shown@;			
LB above in item #12, explain the reason for the delay.@;PU.4,11;PD21,11;			
PU.4,10.7;LB16. If the statement requested in item 1 of the attached instructions is not submitted@;			
LB with this form, explain reason for delay.@;			
PU.4,9.3;PD21,9.3;PU.4,9;LB17. If the medical reports requested in the item 2 of attached instructions@;			
LB are not submitted with this form, explain reason for delay.@;			
PU.4,7.6;PD21,7.6;PU.4,7.1;PD21,7.1;			
PU.4,7.1;RA21,7.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,7.2;LBEmployee Signature@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.4,6.7;LB18. I certify, under penalty of law, that the disease or illness described above@;			
LB was the result of my employment with the United States@;			
PU.9,6.4;LBGovernment, and that it was not caused by my willful misconduct, intent to injure@;			
LB myself or another person, nor by my intoxication.@;			
PU.9,6.1;LBI hereby claim medical treatment, if needed, and other benefits provided@;			
LB by the Federal Employees' Compensation Act.@;			
PU.9,5.5;LBI hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any@;			
PU.9,5.2;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative).@;			
PU.9,4.9;LBThis authorization also permits any official representative of the Office to examine and to copy any records concerning me.@;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU.4,4.4;LBSignature of employee or person acting on his/her behalf@;PU8.8,4.4;PD21,4.4;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU16.3,4.5;LBDate@;			
PU.4,3.9;LBHave your supervisor complete the receipt attached to this form and return it to you for your records.@;			
PU.4,3.4;LBAny person who knowingly makes any false statement, misrepresentation,@;			
LB concealment of fact, or any other act of fraud to obtain compensation@;			
PU.4,3.1;LBas provided by the FECA or who knowingly accepts compensation to which@;			
LB that person is not entitled, is subject to civil or administrative remedies@;			
PU.4,2.8;LBas well as felony criminal prosecution and may, under appropriate provisions, be punished by a fine or imprisonment, or both.@;			
PU.4,2.6;PD21,2.6;			
PU18.5,2.2;LBForm CA-2@;PU18.5,1.8;LBRev. Jan. 1997@;			
PU0.8,25.5;LB			
PU15.9,25.5;LB			
PU6.5,24.7;LB			
PU8.7,24.7;LB			
PU16.6,24.7;LB			
PU0.8,23.5;LB			
PU12.8,22.7;LB			
PU16.2,23.8;LBX@;			
PU16.2,23.4;LBX@;			
PU16.2,23;LBX@;			
PU16.2,23.8;LBX@;PU16.2,23.4;LBX@;			
PU16.2,23.8;LBX@;PU16.2,23;LBX@;			
PU16.2,23.4;LBX@;PU16.2,23;LBX@;			
PU16.2,23.8;LBX@;PU16.2,23.4;LBX@;PU16.2,23;LBX@;			
PU0.8,20.9;LB			
PU16.2,21.1;LB			
PU0.8,19.7;LB			
PU0.8,18.8;LB			
PU0.8,16.9;LB			
PU0.8,16.5;LB			
PU0.8,16.1;LB			
PU0.8,15.7;LB			
PU0.8,15.3;LB			
PU0.8,14.9;LB			
PU7.9,17.6;LBSee Attached@;			
13. Explain the relationship to your employment, and why you came to this realization.			
PU1,13.7;LB			
PU1,12.9;LB			
PU1,13.6;LBSee Attached@;			
14. Nature of disease or illness.			
PU16.2,13.9;LB			
PU16.2,13.0;LB			
PU18.0,13.0;LB			
PU1,11.2;LB			
PU1,12;LBSee Attached@;			
15. If this notice and claim was not filed with the employing agency within			
PU1,10.3;LB			
PU1,9.9;LB			
PU1,9.5;LB			
PU1,10.3LBSee Attached@;			
16. If the statement requested in item 1 of the attached instructions is not			
PU1,8.6;LB			
PU1,8.2;LB			
PU1,7.8;LB			
PU1,8.6LBSee Attached@;			
17. If the medical reports requested in item 2 of attached instructions			
PU9.5,4.5;LB/ES/ 			
PU17.3,4.5;LB			
PU4.2,18.8;PD4.2,19;PU5.1,18.8;PD5.1,19;PU5.9,18.8;PD5.9,19;			
PU3.3,17.5;PD3.3,17.7;PU4.2,17.5;PD4.2,17.7;			
PU.5,13.7;PD21,13.7;PU.5,13.4;LB32. Employee's Retirement Coverage@;			
PU7.2,13.4;EA7.4,13.2;PU7.8,13.2;LBCSRS@;			
PU9.2,13.4;EA9.4,13.2;PU9.8,13.2;LBFERS@;			
PU11.2,13.4;EA11.4,13.2;PU11.8,13.2;LBOther, (Identify)@;			
PU.5,12.3;LB33. 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;LB34. Name and address of third party (Include city, state, and zip code)@;			
PU18.5,2.5;LBForm CA-2@;PU18.5,2.1;LBRev. Jan. 1997@;			
PU0.8,27.4;LB			
PU0.8,26.5;LB			
PU0.8,25.7;LB			
PU0.8,24.8;LB			
PU17.5,24.8;LB			
PU3,23.8;LB			
PU4.1,24.2;LBX@;			
PU4.1,23.8;LBX@;			
PU6.3,23.8;LB			
PU7.4,24.2;LBX@;			
PU7.4,23.8;LBX@;			
PU0.8,22.7;LB			
PU0.8,21.9;LB			
PU0.8,21.1;LB			
PU17.5,21.7;LBX@;			
PU18.9,21.7LBX@;			
PU0.8,16.3;LB			
PU0.8,15.9;LB			
PU0.8,15.5;LB			
PU0.8,15.1;LB			
PU0.8,14.7;LB			
PU0.8,14.3;LB			
PU0.8,13.9;LB			
PU.8,16.2,12.3;LBSee Attached@;			
31. If employee has returned to work and work assignment has changed,			
PU7.2,13.2;LBX@;			
PU9.2,13.2;LBX@			
PU11.2,13.2;LBX@;			
PU1,12.7;LB			
PU0.9,11.5;LBX@;			
PU2.3,11.5;LBX@;			
PU3.8,11.8;LB			
PU3.8,11;LB			
PU3.8,10.2;LB			
PU1,7.5;LB			
PU0.8,5.5;LB			
PU0.8,4.7;LB/ES/ 			
PU12.5,4.7;LB			
PU0.8,3.8;LB			
DT@,1;SD1,277,2,1,4,10,5,0,6,1,7,23;PU.5,28.6;PD21,28.6;			
PU.5,28.3;LBDisability Benefits for Employees under the Federal Employees' Compensation Act (FECA)@;			
PU.5,28.2;FT10,10;RA21,28.6;PU.5,28.2;PD21,28.2;			
PU.5,27.6;LBThe FECA, which is administered by the Office of Workers'@;			
PU10.9,27.6;LBThe first three days in a non-pay status are waiting days, and@;			
PU.5,27.3;LBCompensation Programs (OWCP), provides the following@;			
PU10.9,27.3;LBno compensation is paid for these days unless the period of@;			
PU.5,27;LBgeneral benefits for employment-related occupational disease@;			
PU10.9,27;LBdisability exceeds 14 calendar days, or the employee has@;			
PU.5,26.7;LBor illness:@;			
PU10.9,26.7;LBsuffered a permanent disability. Compensation for total disa-@;			
PU10.9,26.4;LBbility is generally paid at the rate of 2/3 of an employee's@;			
PU10.9,26.1;LBsalary if there are no dependents, or 3/4 of salary if there are@;			
PU10.9,25.8;LBone or more dependents.@;			
PU.5,26;LB(1) Full medical care from either Federal medical officers and@;			
PU1,25.7;LBhospitals, or private hospitals or physicians of the@;			
PU1,25.4;LBemployee's choice.@;			
PU.5,24.6;LB(2) Payment of compensation for total or partial wage loss.@;			
PU.5,23.9;LB(3) Payment of compensation for permanent impairment of@;			
PU1,23.6;LBcertain organs, members, or functions of the body (such as@;			
PU1,23.3;LBloss or loss of use of an arm or kidney, loss of vision, etc.),@;			
PU1,23;LBor for serious disfigurement of the head, face, or neck.@;			
PU.5,22.3;LB(4) Vocational rehabilitation and related services where@;			
PU1,22;LBnecessary.@;			
PU10.9,25.2;LBAn employee may use sick or annual leave rather than LWOP@;			
PU10.9,24.9;LBwhile disabled. The employee may repurchase leave used@;			
PU10.9,24.6;LBfor approved periods. Form CA-7b, available from the@;			
PU10.9,24.3;LBpersonnel office, should be studied BEFORE a decision is@;			
PU10.9,24.0;LBmade to use leave.@;			
PU10.9,23.4;LBIf an employee is in doubt about compensation benefits, the@;			
PU10.9,23.1;LBOWCP District Office servicing the employing agency should@;			
PU10.9,22.8;LBbe contacted. (Obtain the address from your employing@;			
PU10.9,22.5;LBagency.)@;			
PU10.9,21.9;LBFor additional information, review the regulations governing the@;			
PU10.9,21.6;LBadministration of the FECA (Code of Federal Regulations, Title@;			
PU10.9,21.3;LB20, Chapter 1) or Chapter 810 of the Office of Personnel@;			
PU10.9,21.0;LBManagement's Federal Personnel Manual.@;			
PU.5,20.2;PD21,20.2;PU.5,19.7;PD21,19.7;PU.5,19.8;SD1,277,2,1,4,10,5,0,6,1,7,23;LBPrivacy Act@;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,19.7;RA21,20.2;			
PU.5,19.0;LBIn accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'@;			
PU.5,18.5;LBCompensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation@;			
PU.5,18.0;LBPrograms of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)@;			
PU.5,17.5;LBInformation which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be@;			
PU.5,17.0;LBverified through computer matches or other appropriate means. (3) Information may be given to the Federal Agency which employed the@;			
PU.5,16.5;LBclaimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to@;			
PU.5,16.0;LBconsider issues relating to retention, rehire, or relevant matters. (4) Information may also be given to other Federal agencies, other@;			
PU.5,15.5;LBgovernment entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. @;			
PU.5,15.0;LB(5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational@;			
PU.5,14.5;LBrehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be@;			
PU.5,14.0;LBgiven to the Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to@;			
PU.5,13.5;LBdetermine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to@;			
PU.5,13.0;LBpursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7)@;			
PU.5,12.5;LBDisclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and@;			
PU.5,12.0;LBother information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal@;			
PU.5,11.5;LBGovernment, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing@;			
PU.5,11.0;LBof the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.@;			
SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,10.5;LBNote: This notice applies to all forms requesting information that you might receive from the Office in connection with the@;			
PU.5,10.0;LBprocessing and adjudication of the claim you filed under the FECA. @;			
SD1,277,2,1,4,10,5,0,6,1,7,23;PU.5,9.3;LBReceipt of Notice of Occupational Disease or Illness@;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9.7;PD21,9.7;PU.5,9.2;PD21,9.2;			
PU.5,9.2;RA21,9.7;PU.5,8.7;LBThis acknowledges receipt of notice of disease or illness sustained by:@;			
PU.5,8.4;LB(Name of injured employee)@;			
PU.5,7.7;PD21,7.7;PU.5,7.4;LBI was first notified about this condition on (Mo., Day, Yr.)@;			
PU.5,6.9;PD21,6.9:PU.5,6.6;LBAt (Location)@;			
PU.5,5.5;PD21,5.5;PU.5,5.2;LBSignature of Official Superior@;			
PU9.4,5.2;LBTitle@;PU16.3,5.2;LBDate (Mo., Day, Yr.)@;			
PU.5,4.3;PD21,4.3;PU.5,4;LBThis receipt should be retained by the employee as a record that notice was filed.@;			
DT#,1;SD1,277,2,1,4,10,5,0,6,2,7,23;PU.5,28.3;LBInstructions for Completing Form CA-1#;PU.5,28.1;PD21,28.1;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.6;LBComplete all items on your section of the form. If additional space is required to #;			
LBexplain or clarify any point, attach a supplemental#;			
PU.5,27.3;LBstatement to the form. Some of the items on the form which may require #;			
LBfurther clarification are explained below.#			
FT10,10;PU.5,26.5;RA21,27;EA21,27;PU.6,26.6;LBEmployee (Or person acting on the employees' behalf)#;			
PU.5,26.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB13) Cause of Injury#;			
PU11,26.1;LB15) Election of COP/Leave#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,25.7;LBDescribe in detail how and why the injury occurred. Give#;			
PU11,25.7;LBIf you are disabled for work as a result of this injury and filed#;			
PU11,25.4;LBCA-1 within thirty days of the injury, you may be entitled to receive#;			
PU.5,25.4;LBappropriate details (e.g.: if you fell, how far did you fall and in#;			
PU11,25.1;LBcontinuation of pay (COP) from your employing agency. COP is#;			
PU11,24.8;LBpaid for up to 45 calendar days of disability, and is not charged#;			
PU11,24.5;LBagainst sick or annual leave. If you elect sick or annual leave#;			
PU11,24.2;LByou may not claim compensation to repurchase leave used#;			
PU11,23.9;LBduring the 45 days of COP entitlement.#;			
PU.5,25.1;LBwhat position did you land?)#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,24.5;LB14) Nature of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,24.1;LBGive a complete description of the condition(s) resulting from#;			
PU.5,23.8;LByour injury. Specify the right or left side if applicable (e.g.,#;			
PU.5,23.5;LBfractured left leg: cut on right index finger).#;			
PU.5,22.6;RA21,23.1;EA21,23.1;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.6,22.7;LBSupervisor#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,22.1;LBAt the time the form is received, complete the receipt of notice of#;			
PU11,22.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB33) First date medical care received#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,21.8;LBinjury and give it to the employee. In addition to completing#;			
PU.5,21.5;LBitems 17 through 39, the supervisor is responsible for obtaining#;			
PU11,21.6;LBThe date of the first visit to the physician listed in item 31.#			
PU.5,21.2;LBthe witness statement in item 16 and for filling in the proper codes#;			
PU.5,20.9;LBin shaded boxes a, b, and c on the front of the form. If medical#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20.8;LB36) If the emloying agency controverts continuation#;			
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