English	French	Notes	Complete/Exclude
PU11.5,20.4;LBof pay, state, the reason in detail#;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,20.6;LBexpense or lost time is incurred or expected, the completed form#;			
PU.5,20.3;LBshould be sent to OWCP within 10 working days after it is received.#;			
PU.5,19.5;LBThe supervisor should also submit any other information or#;			
PU.5,19.2;LBevidence pertinent to the merits of this claim.#;			
PU11,19.9;LBCOP may be controverted (disputed) for any reason; however,#;			
PU11,19.6;LBthe employing agency may refuse to pay COP only if the#;			
PU11,19.3;LBcontroversion is based upon one of the nine reasons given#;			
PU11,19;LBbelow:#			
PU.5,18.5;LBIf the employing agency controverts COP, the employee should#;			
PU11,18.4;LBa) The disability was not caused by a traumatic injury.#;			
PU.5,18.2;LBbe notified and the reason for controversion explained to him or#;			
PU.5,17.9;LBher.#;			
PU11,17.7;LBb) The employee is a volunteer working without pay or for#;			
PU11.5,17.4;LBnominal pay, or a member of the office staff of a former#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,17.2;LB17) Agency name and address of reporting office#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU11.5,17.1;LBPresident;#;			
PU.5,16.7;LBThe name and address of the office to which correspondence#;			
PU11,16.6;LBc) The employee is not a citizen or a resident of the United#;			
PU.5,16.4;LBfrom OWCP should be sent (if applicable, the address of the#;			
PU11.5,16.3;LBStates or Canada;#;			
PU.5,16.1;LBpersonnel or compensation office).#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,15.5;LB18) Duty station street address and zip code#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU11,15.6;LBd) The injury occurred off the employing agency's premises and#;			
PU11.5,15.3;LBthe employee was not involved in official 			
off premise			
PU.5,15;LBThe address and zip code of the establishment where the#;			
PU.5,14.7;LBemployee actually works.#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,14.1;LB19) Employers Retirement Coverage.#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,13.7;LBIndicate which retirement system the employee is covered under.#;			
PU11,14.5;LBe) The injury was proximately caused by the employee's willful#;			
PU11.5,14.2;LBmisconduct, intent to bring about injury or death to self or#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LB30) Was injury caused by third party?#;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU11.5,13.9;LBanother person, or intoxication;#;			
PU.5,12.4;LBA third party is an individual or organization (other than the#;			
PU.5,12.1;LBinjured employee or the Federal government) who is liable for#;			
PU11,13.1;LBf) The injury was not reported on Form CA-1 within 30 days#;			
PU.5,11.8;LBthe injury. For instance, the driver of a vehicle causing an#;			
PU11.5,12.8;LBfollowing the injury;#;			
PU.5,11.5;LBaccident in which an employee is injured, the owner of a#;			
PU.5,11.2;LBbuilding where unsafe conditions cause an employee to fall, and#;			
PU11,12.1;LBg) Work stoppage first occurred 45 days or more following#;			
PU.5,10.9;LBa manufacturer whose defective product causes an employee's#;			
PU11.5,11.8;LBthe injury;#;			
PU.5,10.6;LBinjury, could all be considered third parties to the injury.#;			
PU11,11.1;LBh) The employee initially reported the injury after his or her#;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,9.8;LB32) Name and address of physician first providing#;PU.5,9.4;LBmedical care#;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11.5,10.8;LBemployment was terminated; or#;			
PU11,10.1;LBi) The employee is enrolled in the Civil Air Patrol, Peace Corps,#;			
PU.5,8.9;LBThe name and address of the physician who first provided#;			
PU11.5,9.8;LBYouth Conservation Corps, Work Study Programs, or other#;			
PU.5,8.6;LBmedical care for this injury. If initial care was given by a nurse#;			
PU11.5,9.5;LBsimilar groups.#;			
PU.5,8.3;LBor other health professional (not a physician) in the employing#;			
PU.5,8;LBagency's health unit or clinic, indicate this on a separate sheet#;			
PU.5,7.7;LBof paper.#;			
PU.5,6.6;EA21,7.1;RA21,7.1;PU.6,6.7;SD1,277,2,1,4,9,5,0,6,2,7,23;			
PU.6,6.7;LBEmploying Agency - Required Codes#;			
PU.5,6.2;LBBox a (Occupation Code), Box b (Type Code),#;			
PU.5,5.8;LBBox c (Source Code), OSHA Site Code#;PU11,6.2;LBOWCP Agency Code#;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11,5.6;LBThis is a four-digit (or four digit plus two letter) code used by#;			
PU.5,5.3;LBThe Occupational Safety and Health Administration (OSHA)#;			
PU11,5.3;LBOWCP to identify the employing agency. The proper code may#;			
PU.5,5;LBrequires all employing agencies to complete these items when#;			
PU11,5;LBbe obtained from your personnel or compensation office, or by#;			
PU.5,4.7;LBreporting an injury. The proper codes may be found in OSHA#;			
PU11,4.7;LBcontacting OWCP.#;			
PU.5,4.4;LBBooklet 2014, Recordkeeping and Reporting Guidelines.#;			
PU.5,4;PD21,4;PU18,3.5;LBForm CA-1#;PU18,3;LBRev. Apr. 1999#;			
IN;SP1;IP;PW.2;SC0,22,0,29,1;			
DT@,1;SD1,277,2,1,4,10,5,0,6,2,7,23;			
PU.5,28.3;LBInstructions for Completing Form CA-2@;			
PU.5,28.1;PD22,28.1;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.7;LBComplete all items on your section of the form. If additional space is required @;			
LBto explain or clarify any point, attach a supplemental@;			
PU0.5,27.4;LBstatement to the form. In addition to the information requested on the form, both the employee @;			
LBand the supervisor are required to @;			
PU0.5,27.1;LBsubmit additional evidence as decribed below. If this evidence is not submitted @;			
LBalong with the form, the responsible party should@;			
PU0.5,26.8;LBexplain the reason for the delay and state when the additional evidence will be submitted.@;			
PU.5,26.6;PD22,26.6;PU.5,26.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmployee@;			
LB (or person acting on the employee's behalf)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,26.1;PD22,26.1;PU.5,26.1;FT10,10;RA22,26.6;			
PU0.5,25.7;LBComplete items 1 through 18 and submit the form to the employee's supervisor @;			
LBalong with the statement and medical reports described@;			
PU0.5,25.4;LBbelow. Be sure to obtain the Receipt of Notice of Disease or Illness completed @;			
LBby the supervisor at the time the form is submitted.@;			
SD1,277,2,1,4,9,5,0,6,2,7,23;PU0.5,25;LB1) Employee's statement@;			
PU11,25;LB2) Medical report@;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU0.5,24.7;LBIn a separate narrative statement attached to the form the@;			
PU0.5,24.4;LBemployee must submit the following information:@;			
PU1,24;LBa) A detailed history of the disease or illness from the date it@;			
PU1.3,23.7;LBstarted.@;			
PU1,23.3;LBb) Complete details of the conditions of employment which are@;			
PU1.3,23;LBbelieved to be responsible for the disease or illness.@;			
PU1,22.6;LBc) A description of specific exposures to substances or stress-@;			
PU1.3,22.3;LBful conditions causing the disease or illness, including loca-@;			
PU1.3,22;LBtions where exposure or stress occurred, as well as the@;			
PU1.3,21.7;LBnumber of hours per day and days per week of such@;			
PU1.3,21.4;LBexposure or stress.@;			
PU1,21;LBd) Identification of the part of the body affected. (If disability is@;			
PU1.3,20.7;LBdue to a heart condition, give complete details of all@;			
PU1.3,20.4;LBactivities for one week prior to the attack with particular@;			
PU1.3,20.1;LBattention to the final 24 hours of such period.)@;			
PU1,19.7;LBe) A statement as to whether the employee ever suffered a@;			
PU1.3,19.4;LBsimilar condition. If so, provide full details of onset, history,@;			
PU1.3,19.1;LBand medical care received, along with names and addres-@;			
PU1.3,18.8;LBses of physicians rendering treatment.@;			
PU11.5,24.6;LBa) Dates of examination or treatment.@;			
PU11.5,24.2;LBb) History given to the physician by the employee.@;			
PU11.5,23.8;LBc) Detailed description of the physician's findings.@;			
PU11.5,23.4;LBd) Results of x-rays, laboratory tests, etc.@;			
PU11.5,23;LBe) Diagnosis.@;PU11.5,22.6;LBf) Clinical course of treatment.@;			
PU11.5,22.2;LBg) Physician's opinion as to whether the disease or illness@;			
PU11.8,21.9;LBwas caused or aggravated by the employment, along with@;			
PU11.8,21.6;LBan explanation of the basis for this opinion. (Medical@;			
PU11.8,21.3;LBreports that do not explain the basis for the physician's@;			
PU11.8,21;LBopinion are given very little weight in adjudicating the@;			
PU11.8,20.7;LBclaim.)@;SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20;LB3) Wage loss@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU11.5,19.6;LBIf you have lost wages or used leave for this illness, Form@;PU11.5,19.3;LBCA-7 should also be submitted.@;			
PU.5,18.6;PD22,18.6;			
PU.5,18.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBSupervisor@;			
LB  (Or appropriate official in the employing agency)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU.5,18.1;PD22,18.1;PU.5,18.1;RA22,18.6;			
PU.5,17.7;LBAt the time the form is received, complete the Receipt of Notice of Disease or Illness and give @;			
LBit to the employee. In addition to completing@;			
PU.5,17.4;LBitems 19 through 34, the supervisor is responsible for filling in the proper codes @;			
LBin shaded boxes a, b, and c on the front of the form. If@;			
PU.5,17.1;LBmedical expense or lost time is incurred or expected, the completed form @;			
LBmust be sent to OWCP within ten working days after it is@;			
PU.5,16.8;LBreceived. In a separate, narrative statement attached to the form, the supervisor must:@;			
PU.5,16.4;LBa) Describe in detail the work performed by the employee. Identify@;			
PU11,16.4;LBc) Attach a record of the employee's absence from work caused@;			
PU1,16.1;LBfumes, chemicals, or other irritants or situations that the employ-@;			
PU11.5,16.1;LBby any similar disease or illness. Have the employee state the@;			
PU1,15.8;LBee was exposed to which allegedly caused the condition. State@;PU11.5,15.8;LBreason for each absence.@;			
PU1,15.5;LBthe nature, extent, and duration of the exposure, including hours@;			
PU11,15.4;LBd) Attach statements from each co-worker who has first-hand@;			
PU1,15.2;LBper days and days per week, requested above.@;PU11.5,15.1;LBknowledge about the employee's condition and its cause. (The@;			
PU.5,14.8;LBb) Attach copies of all medical reports (including x-ray reports and@;			
PU11.5,14.8;LBco-workers should state how such knowledge was obtained.)@;			
PU1,14.5;LBlaboratory data) on file for the employee.@;			
PU11,14.4;LBe) Review and comment on the accuracy of the employee's state-@;PU11.5,14.1;LBment requested above.@;			
PU.5,13.7;LBThe supervisor should also submit any other information or evidence pertinent @;			
LBto the merits of this claim.@;			
PU.5,13.5;PD22,13.5;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LBItem Explanations@;			
LB  Some of the items on the form which may require further clarification are explained below.@;			
PU.5,13;PD22,13;PU.5,13;RA22,13.5;			
PU.5,12.5;LB14. Nature of the disease or illness@;			
PU1,12.1;LBGive a complete description of the disease or illness. Specify@;			
PU1,11.8;LBthe left or right side if applicable (e.g., rash on left leg; carpal@;			
PU1,11.5;LBtunnel syndrome, right wrist).@;			
SD1,277,2,1,4,9,5,0,6,2,7,23;			
PU.5,10.8;LB19. Agency name and address of reporting office@;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
PU1,10.4;LBThe name and address of the office to which correspondence@;			
PU1,10.1;LBfrom OWCP should be sent (If applicable, the address of the@;			
PU1,9.8;LBpersonnel or compensation office).@;			
PU.5,8.9;LB23. Name and address of physician first providing@;			
PU1,8.5;LBmedical care@;			
PU1,8.1;LBThe name and address of the physician who first provided@;			
PU1,7.8;LBmedical care for this injury. If initial care was given by a@;			
PU1,7.5;LBnurse or other health professional (not a physician) in the@;			
PU1,7.2;LBemploying agency's health unit or clinic, indicate this on a@;			
PU1,6.9;LBseparate sheet of paper.@;			
PU11,12.5;LB24. First date medical care received@;			
PU11.5,12.2;LBThe date of the first visit to the physician listed in item 23.@;			
PU11,10.8;LB32. Employee's Retirement Coverage.@;			
PU11.5,10.4;LBIndicate which retirement system the employee is covered@;			
PU11.5,10.1;LBunder.@;			
PU11,9.2;LB33. Was the injury caused by third party?@;			
PU11.5,8.9;LBA third party is an individual or organization (other than the@;			
PU11.5,8.6;LBinjured employee or the Federal government) who is liable for@;			
PU11.5,8.3;LBthe disease. For instance, manufacturer of a chemical to which@;			
PU11.5,8;LBan emoloyee was exposed might be considered a third party if@;			
PU11.5,7.7;LBimproper instructions were given by the manufacturer for use of@;			
PU11.5,7.4;LBthe chemical.@;			
PU.5,6.2;PD22,6.2;PU.5,5.8;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmploying Agency - Required Codes@;			
PU.5,5.7;PD22,5.7;PU.5,5.7;RA22,6.2;			
PU.5,5.2;LBBox a (Occupation Code), Box b (Type Code), Box c@;			
PU.5,4.8;LB(Source Code), OSHA Site Code@;PU11,5.2;LBOWCP Agency Code@;			
SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,4.4;LBThe Occupational Safety and Health Administration (OSHA)@;			
PU11,4.8;LBThis is a four digit (or four digit two letter) code used by@;			
PU11,4.5;LBOWCP to identify the employing agency. The proper code@;			
PU11,4.2;LBmay be obtained from your personnel or compensation office,@;			
PU.5,4.1;LBrequires all employing agencies to complete these items when@;			
PU11,3.9;LBor by contacting OWCP.@;			
PU.5,3.8;LBreporting an injury. The proper codes may be found in OSHA@;			
PU.5,3.5;LBBooklet 2014, Record Keeping and Reporting Guidelines.@;			
PU.5,3;PD22,3;SD1,277,2,1,4,9,5,0,6,0,7,16901;			
The CA-1 and CA-2 forms require a Hewlett Packard laser jet			
(or compatible) printer with PCL (Printer Control Language)			
Level 5.  Do NOT select the home device.			
NOTICE OF TRAUMATIC INJURY			
CA-1			
Federal Employee's Notice of Traumatic Injury and Claim for Continuation of			
Pay/Compensation (Continued)			
CA-2			
Notice of Occupational Disease and Claim for Compensation (Continued)			
Select case: 			
SUPERVISOR...................:			
VOLUNTARY SVC SUPERVISOR.....:			
CONTRACT ADMINISTRATOR.......:			
SAFETY OFFICER...............:			
CASE NUMBER..................: 			
PERSONNEL STATUS.............: 			
SERVICE......................: 			
TYPE OF INCIDENT.............: 			
CASE STATUS..................: 			
INJURY/ILLNESS...............: 			
PERSON INVOLVED..............: 			
SSN..........................: 			
DATE OF BIRTH................: 			
SEX..........................: 			
HOME ADDRESS.................: 			
HOME PHONE NUMBER............: 			
STATION NUMBER...............: 			
COST CENTER/ORG..............: 			
OCCUPATION...................: 			
GRADE/STEP...................: 			
EDUCATION....................: 			
SECONDARY SUPERVISOR.........: 			
DATE/TIME OF OCCURRENCE......: 			
GENERAL SETTING OF INCIDENT..: 			
LOCATION OF INCIDENT.........: 			
CHARACTERIZATION OF INJURY...: 			
MEDICAL EMERGENCY............: 			
BODY PART MOST AFFECTED......: 			
ADDITIONAL BODY PART AFFECTED: 			
SIDE OF BODY AFFECTED........: 			
DUTY RETURNED TO.............: 			
LOST TIME....................: 			
DESCRIPTION OF INCIDENT......:			
PATIENT SOURCE...............: 			
CONTAMINATION................: 			
PURPOSE OF SHARP OBJECT......: 			
ACTIVITY AT TIME OF INJURY...: 			
OBJECT CAUSING INJURY........: 			
DEVICE SIZE..................: 			
BRAND........................: 			
AREA EXPOSED TO BODILY FLUID.: 			
PERSONAL PROTECTIVE EQUIPMENT: 			
BODILY FLUID EXPOSURE SOURCE.: 			
EQUIPMENT/DEVICE FAILURE.....: 			
SAFETY DESIGN DEVICE USED....: 			
DID INJURY OCCUR BEFORE			
 SAFETY DEVICE WAS ENGAGED...: 			
SAFETY CHARACTERISTICS.......: 			
EXPLAIN WHY SAFE DEV NOT USED: 			
CORRECTIVE ACTION............: 			
SAFETY OFF. COMMENTS.........: 			
PERSON ENTERING STUB RECORD..: 			
SUPERVISOR SIGNATURE DATE....: 			
/ES/SAFETY OFFICER...........: 			
SAFETY OFFICER SIGNATURE DATE: 			
ASISTS REPORT OF ACCIDENT			
Report of Accident 			
Select the Fiscal Year or RETURN for ALL: 			
Enter the Fiscal Year that you want to print for or RETURN for data in file			
You must enter a 4 digit year.			
No date for that Fiscal Year please select again.			
Print Accident Report Sign-off list			
EMPLOYEE:			
UN-			
SUPERVISOR:			
SAFETY OFFICER:			
Accident Report Status			
 for the fiscal Year 			
DATE OF INCIDENT			
Select Form: 			
Select the form to be printed.			
Print a 			
Select Case: 			
51 CASE STATUS..................//C			
47 CORRECTIVE ACTION TAKEN......			
55 SAFETY OFF. COMMENTS.........			
The Employee portion of the CA			
 has not been signed.			
The Supervisor portion of the CA			
The Employee or Supervisor has not signed their			
part of the CA Claim form.			
Signing the form now closes the case and removes			
it from everyone's selection list for editing.			
Do you want to sign the Case			
 CASE STATUS..................			
58 REASON FOR DELETION.........			
1) VA FORM 2162 			
Injury (CA1			
Illness (CA2			
 Select form: 			
 Select the form to be edited.			
Another user is editing this entry. Try later.			
The employee has not signed the 			
Supervisor must sign before Safety Officer			
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.........: 			
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