Form CA-1 Federal Employee's Notice of Traumatic Injury and ...
Explanation of Form CA-1 IMPORTANT You must click your mouse, press Enter, or use your arrow keys on your keyboard to move throughout this slide show. Form CA-1 Federal Employees Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation The Form CA-1 was developed to ensure regulatory compliance and to be more customer friendly. The form must be completed by the injured employee, a witness, and the injured employees supervisor. Process of Form CA-1 Form CA-1 is available at: http://www.dol.gov/esa/regs/compliance/owcp/ca-1.pdf Steps to Complete Form CA-1: (1) The employee, who is claiming traumatic injury and claim for continuation of pay/compensation, must complete all boxes 1-15, including signature. (2) The witness must then complete box 16, including signature. (3) The supervisor must complete the Supervisors Report, 17-38, including signature. They must also complete the Privacy Act Section on page 3. (4) Page 2, box 39, supervisor must check the appropriate filing instructions box. Where Where there there is is aa box to indicate aa choice, choice, simply simply click click on the appropriate appropriate box to to make make your your selection selection Enter EnterALL ALLIdentifying Identifying information informationininthe the appropriate
appropriateboxes boxes 123-45-5678 987-654-3210 13) Describe in detail how how and and why why the the injury injury occurred. occurred. Give Give appropriate appropriate details details (e.g.: (e.g.: ifif you you fell, fell, how how far far did did you you fall fall and and in in what position position did did you you land?) land?) 14) 14) Give Give complete complete description description of of the the condition(s) condition(s) resulting resulting from your injury. specify specify the the right right or or left left side side ifif applicable applicable (e.g.: (e.g.: fractured fractured left left leg; leg; cut cut on on right
index index finger). finger). This section will be filled out by your workers compensation contact. The list of contacts can be found on the last slide. Employee Signature 15) 15) IfIf you you are are disabled disabled for for work work as as a result result of of this this injury injury and and file file CA-1 CA-1 within within thirty days of the injury, you are entitled to receive continuation of of pay pay (COP) (COP) from from your your employing employing agency. agency. COP COP is is paid paid for for up up to to 45 45 calendar calendar days of disability, disability, and and is is not not charged charged against against sick sick or or annual annual leave. leave. You may elect sick or annual leave if you wish, but compensation from from OWCP OWCP may may not not be be claimed claimed during
during the the 45 45 days days of of COP COP entitlement. entitlement. (You (You may not not claim claim compensation compensation to to repurchase repurchase leave leave used used during during this this period.) period.) Also, if you change your election within one year, the agency is obliged obliged to convert past periods of leave to COP, which qualify. Your Your agency agency may may controvert (dispute) your entitlement entitlement to to COP, but must continue pay unless the controversion is COP, but must based based on on one one of of the the nine nine reasons reasons listed listed in in the the instructions instructions for for item 35. item IfIf you you receive receive COP, COP, but but OWCP OWCP later later determines determines that that you you are are not
not entitled entitled to to COP, COP, you you may may either either change change COP COP to to sick sick or or annual annual leave leave or or pay pay the the employing employing agency back for the COP received. received. Witness Signature Supervisor At the time of the form is received, complete the receipt of notice of injury and give it to the employee. In addition to completing items 17 through 38, the supervisor is responsible for obtaining the witness statement in item 16 and for filling in the proper codes in shaded boxes a, b, and c on the front of the form. If medical expense or lost time is incurred or expected, the completed form should be sent to Workers Compensation contact within 3 working days after it is received. The Supervisor should also submit any other information or evidence pertinent to the merits of this claim. If the employing agency controverts COP, the employee should be notified and the reason for controversion explained to him or her. 17) 17) The The name name and and address of the office office to to which which correspondence from from OWCP OWCP should should be be sent sent (if (if applicable, applicable, the the address address of of the the personnel personnel or
or compensation). compensation). 30) 30) A A third third party party is is an an individual individual or or organization organization (other (other than than the the injured injured employee employee or or the the federal federal government) government) who who is is liable liable for for the the injury. injury. For For instance, instance, the the driver driver of of aa vehicle vehicle causing causing an an accident accident in in which which an an employee employee is is injured, injured, the the owner owner of of aa building building where where unsafe unsafe conditions conditions cause cause an an employee employee
to to fall, fall, and and aa manufacturer manufacturer whose whose defective defective product product causes causes an an employees employees injury, injury, could could all all be be considered considered third third parties parties to to the the injury. injury. 18) 18) The The address address and and zip code the zipfor code of the 36) any reason; 36) COP COP may may be be controverted controverted (disputed) (disputed) for any of reason; where establishment however, refuse however, the the employing employing agency agency may mayestablishment refuse to to pay pay COP COP the employee
actually only if the controversion is based upon one of the nine the employee only if the controversion is based upon one of the nine reasons works reasons given given below: below: works 19) 19) Indicate Indicate which which retirement retirement system system the the employee employee is is covered covered under. under. a) a) The The disability disability results results from from an an occupational occupational disease disease or or illness; illness; b) b) The The employee employee is is aa volunteer volunteer working working without without pay pay or or for for nominal nominal pay, pay, or or aa member member of of the the office
office staff staff of of aa former former President; President; c) c) The The employee employee is is neither neither aa citizen citizen or or aa resident resident of of the the United United States States or or Canada; Canada; d) d) The The injury injury occurred occurred off off the the employing employing agencys agencys premises premises and and the the employee employee was was not not involved involved in in official official off off premise premise duties; duties; e) e) The The injury injury was was approximately approximately caused caused by by the the employees employees willful willful misconduct, misconduct, intent intent to to bring bring about about injury injury or or death death to to self self
or or another another person, person, or or intoxication; intoxication; f) days f) The The injury injury was was not not reported reported on on Form Form CA-1 CA-1 within within 30 30 days 33) The 33) The date date of of the the following following the the injury; injury; first first visit visit to to the the g) the g) Work Work stoppage stoppage first first occurred occurred 90 90 days days or or more more following following the listed in physician physician injury; injury; item item 32. 32. h) h) The The employee employee initially initially reported reported the the injury injury after after his his or or her
her employment employment was was terminated; terminated; or, or, i)i) The The employee employee is is enrolled enrolled in in the the Civil Civil Air Air Patrol, Patrol, Peace Peace 32) name and 32) The The name Corps, Corps, Work Study Corps, Youth Youth Conservation Conservation Corps, Workand Study address of the the Programs, groups. Programs, or or other other similar similaraddress groups. of physician physician who who first first provided provided medical medical care care for for this this injury. injury. IfIf initial initial care care was was given given by by aa nurse nurse or or other other health health
professional professional (not (not aa physician) physician) in in the the employing employing agencys agencys health health unit unit or or clinic, clinic, indicate indicate this this on on aa separate separate sheet sheet of of paper. paper. Supervisors Signature Privacy Privacy Act Act Supervisors Supervisors Signature Signature Receipt of Notice of Injury Supervisor will give this receipt to the injured employee. Workers Compensation Contact List Click Here Click on the button to view the list of Workers Compensation Contacts QUESTIONS? If you have any questions on completing this form, please contact: Denise Coleman OWCP Program Manager 301-734-8350 or Marquess Commodore Workers Compensation Specialist 301-734-8133 Safety, Health, and Employee Wellness Branch
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