| Federa l Employee s Notice of U.S . Departmen t of Labor Traumatic Injury and Claim for Employment St andards Administration Continuation of Pay/Compensation Office of Workers Compensation Programs Emplo yee: Pleas e complete all boxes 1 - 15 below . Do not comple te sha ded area s. Witness : Complet e bottom secti on 16.
Emplo ying Agency (S upervisor or Compens ation Specialist) : Complet e shaded boxes a, b, and c.
Empl oyee Data 1. Name of employee (Last, First, Middle) 2. So cial Security Number 3. Date of birth Mo. Day Yr. 4. Sex 5. Home telephone 6. Grade as of Male Female date of injuryLevel S tep 7. Employees home mailing address (Include city, state , and ZIP code) 8. Dependents Wife, Husband Children under 18 years
Other
Descriptio n of Injury 9. Plac e where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine) 10. Date injury occurred Time 11. Date of this notice 12. Employees occupation Mo. Day Yr. a.m. Mo. Day Yr. p.m. 13. Cause of injury (Describe what happened and why)
a. Occupation code
14. Natu re of injury (Identify both the injury and the part of body, e.g., fracture of left leg) b. Type code c. Source code
OWCP Use - NOI Code
Empl oyee Signature 15. I certify, under penalty of law, that the injury described above was sustained in performance of duty as an employee of the United Sta tes Government and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my i nto xica tio n. I hereby cl aim m edci al treatm en,t if needed, and the foll o wing, as checked bel ow, whi el di sabled for work: a. Conti nuati on of regul ar pay (COP) not to exceed 45 days and com pensation for wage l oss i f di sabil i ty for work conti nues beyond 45 days. If my claim is denied, I understand that the conti nuati on of m y regular pay shal l be charged to si ck or annual leave, or be deemed an overpayment within the meaning of 5 US C 5584. b. Si ck and/or A nnual Leave I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desire d information to the U.S. Department of Labor, Office of Workers Compensation Programs (or to its official representative). This authorization also permits any official representative of the Office to examine and to copy any records concerning me. Si gnature of em ployee or pers on actin g on his/h er behalf Date Any person who knowingly makes any false stateme nt, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by the FEC A or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.
Have your superviso r complet e the receipt attached to this form and return it to you for your records.
Witness Statement 16. S tatement of witness (Describ e what you saw, heard, or know about this injury) Name of witness Signatur e of witness Date signed Address City State ZIP Code Form CA-1 Rev. Apr. 1999<<<<<<<<<********>>>>>>>>>>>>> 2
Officia l Su pervisor s Report: Pleas e complet e informatio n requested below: Supervisor s Report 17. Agency name and address of reporting office (include city, state, and zip code) OWCP Agency Code OSHA Site Code ZIP Code 18. Employees duty statio n (Stree t address and ZIP code) 19. Employees retirement coverage CSRS FERS Other, i(denti fy) 20. Regular 21. Regular work a.m. a.m. work hours From: To: schedule Sun. Mon. Tues. Wed. Thurs. Fri. Sa t. p.m. p.m. 22. Date Mo. Day Yr. 23. Date Mo. Day Yr. 24. Date Mo. Day Yr. a.m. of notice stopped Injury received work Time: p.m. 25. Date Mo. Day Yr. 26. Date Mo. Day Yr. 27. Date Mo. Day Yr. pay 45 day returned a.m. stopped period began to work Time: p.m. 28. Was employee injured in performance of duty? Yes No (If "No," explain) 29. Was injury caused by employees willful misconduct, intoxication, or intent to injure self or another? Yes (If "Yes," explain) No 30. Was injury causde 31. Name and address of third party (Include city, state , and ZIP code) by third party? Yes No (If "No," go to item 32.) 32. Name and address of physician first providing medical care (Include city, state, ZIP code) 33. First date Mo. Day Yr. medical care received 34. Do medical Yes No reports show employee is disable d for work? 35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses? Yes No (If "No," explain) 36. If the employing agency controverts continuation of pay, state the reason in detail. 37. Pay rate when employee
stopped work
$ Per Sign at ure of Superviso r and Filing Inst ruct ions
38.A supervisor who knowingly certifies to any false statement, misrepresentation, concealm ent of fac t, etc., in respect of this claim may also be subject to appropriate felony criminal prosecution. I certify that the information given above and that furnished by the employee on the reverse of this form is true to the best of my knowledge with the following exception: Name of supervisor (Type or print) Signatur e of supervisor Date Supervisors Title Office phone 39. Filing instucrtions No lost time and no medical expense: Plac e this form in employees medical folder (SF-66-D) No lost time, medical expense incurred or expected: forward this form to OWCP Lost time covered by leave, LWOP, or COP: forward this form to OWCP First Aid Injury Form CA-1, Rev. Apr. 1999<<<<<<<<<********>>>>>>>>>>>>> 3 Instructions for Completing Form CA-1 Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental statement to the form. Som e of the items on the form which may require further clarification are explained below.
Emplo yee (Or person acting on the employees behalf) 13) Caus e of injury 15) Electio n of COP/Leave Describe in detail how and why the injury occurred. Give If you are disabled for work as a result of this injury and filed appropriate details (e.g.: if you fell, how far did you fall and in CA-1 within thirty days of the injury, you may be entitled to receive what position did you land? ) continuation of pay (COP ) from your employing agency. COP is paid for up to 4 | File Types Available:
 Non-fillable PDF
 Fillable MS Word
 Fillable PDF
Posted: 5/2/2006
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