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Ca 1 CA - (AFGE Local 1040 Members)

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FederalEmployee'sNoticeof
TraumaticInjuryandClaimfor
ContinuationofPay/Compensation
U.S.DepartmentofLabor
EmploymentStandardsAdministration
OfficeofWorkers'CompensationPrograms
Employee:Pleasecompleteallboxes1-15below.Donotcompleteshadedareas.
Witness:Completebottomsection16.
EmployingAgency(SupervisororCompensationSpecialist):Completeshadedboxesa,b,andc.
EmployeeData
1.Nameofemployee(Last,First,Middle) 2.SocialSecurityNumber
3.Dateofbirth Mo.DayYr. 4.Sex
Male Female
5.Hometelephone
6.Gradeasof
dateofinjury
Level Step
7.Employee'shomemailingaddress(Includecity,state,andZIPcode)
DescriptionofInjury
9.Placewhereinjuryoccurred(e.g.2ndfloor,MainPostOfficeBldg.,12th&P ine)
10.Dateinjuryoccurred
Mo.DayYr.
Time
a.m.
p.m.
11.Dateofthisnotice
Mo.DayYr.
12.Employee'soccupation
13.Causeofinjury(Describewhathappenedandwhy)
14.Natureofinjury(Identifyboththeinjuryandthepartofbody,e.g.,fractureofleftleg)
a.Occupationcode
b.Typecode c.Sourcecode
OWCPUse-NOICode
EmployeeSignature
15.Icertify,underpenaltyoflaw,thattheinjurydescribedabovewassustainedinperformanceofdutyasanemployeeofthe
UnitedStatesGovernmentandthatitwasnotcausedbymywillfulmisconduct,intenttoinjuremyselforanotherperson,norby
myi ntoxi cati on.Iherebycl ai mm edicaltreatm ent,i fneeded,andthefoll owi ng,ascheckedbel ow,whi l edi sabledforwork:
a. Conti nuati onofregul arpay(COP)nottoexceed45daysandcom pensationforwagel ossi fdi sabil i tyforworkconti nues
beyond45days.Ifm yclai mi sdenied,Iunderstandthattheconti nuati onofm yregularpayshal lbechargedtosi ck
orannualleave,orbedeemedanoverpaymentwithinthemeaningof5USC5584.
b. Si ckand/orA nnualLeave
Iherebyauthorizeanyphysicianorhospital(oranyotherperson,institution,corporation,orgovernmentagency)tofurnishany
desiredinformationtotheU.S.DepartmentofLabor,OfficeofWorkers'CompensationPrograms(ortoitsofficialrepresentative).
ThisauthorizationalsopermitsanyofficialrepresentativeoftheOfficetoexamineandtocopyanyrecordsconcerningme.
Signatureofemployeeorpersonactingonhis/herbehalf Date
Anypersonwhoknowinglymakesanyfalsestatement,misrepresentation,concealmentoffactoranyotheractoffraudtoobtaincompensation
asprovidedbytheFECAorwhoknowinglyacceptscompensationtowhichthatpersonisnotentitledissubjecttociviloradministrative
remediesaswellasfelonycriminalprosecutionandmay,underappropriatecriminalprovisi ons,bepunishedbyafineorimprisonmentorboth.
Haveyoursupervisorcompletethereceiptattachedtothisformandreturnittoyouforyourrecords.
WitnessStatement
16.Statementofwitness(Describewhatyousaw,heard,orknowaboutthisinjury)
Nameofwitness Signatureofwitness Datesigned
Address City State ZIPCode
FormCA-1
Rev.Apr.1999
8.Dependents
Wife,Husband
Childrenunder18years
Other
Reset
Print
OfficialSupervisor'sReport:Pleasecompleteinformationrequestedbelow:
Supervisor'sReport
17.Agencynameandaddressofreportingoffice(includecity,state,andzipcode) OWCPAgencyCode
OSHASiteCode
ZIPCode
18.Employee'sdutystation(StreetaddressandZIPcode)
20.Regular
work
hoursFrom: To:
21.Regular
work
schedule Sun. Mon. Tues. Wed. Thurs. Fri. Sat.
29.Wasinjurycausedbyemployee'swillfulmisconduct,intoxication,orintenttoinjureselforanother? Yes(If"Yes,"explain) No
22.Date Mo. Day Yr.
of
Injury
a.m.
p.m.
a.m.
p.m.
25.Date Mo. Day Yr.
pay
stopped
23.Date Mo. Day Yr.
notice
received
26.Date Mo. Day Yr.
45day
periodbegan
24.Date Mo. Day Yr.
stopped
work Time:
27.Date Mo. Day Yr.
returned
towork Time:
a.m.
p.m.
a.m.
p.m.
28.Wasemployeeinjuredinperformanceofduty? Yes No(If"No,"explain)
35.Doesyourknowledgeofthefactsaboutthisinjuryagreewithstatementsoftheemployeeand/orwitnesses? Yes No (If"No,"explain)
30.Wasinjurycaused
bythirdparty?
Yes No
(If"No,"
goto
item32.)
33.Firstdate Mo. Day Yr.
medicalcare
received
31.Nameandaddressofthirdparty(Includecity,state,andZIPcode)
32.Nameandaddressofphysicianfirstprovidingmedicalcare(Includecity,state,ZIPcode)
34.Domedical
reportsshow
employeeis
disabledforwork?
Yes No
36.Iftheemployingagencycontrovertscontinuationofpay,statethereasonindetail.
37.Payrate
whenemployee stopped work
$Per
SignatureofSupervisorandFilingInstructions
38.Asupervisorwhoknowinglycertifiestoanyfalsestatement,misrepresentation,concealmentoffact,etc.,inrespectofthisclaim
mayalsobesubjecttoappropriatefelonycriminalprosecution.
Icertifythattheinformationgivenaboveandthatfurnishedbytheemployeeonthereverseofthisformistruetothebestofmy
knowledgewiththefollowingexception:
Nameofsupervisor(Typeorprint)
Signatureofsupervisor
Supervisor'sTitle Officephone
Date
39.Filinginstructions Nolosttimeandnomedicalexpense:Placethisforminemployee'smedicalfolder(SF-66-D)
Nolosttime,medicalexpenseincurredorexpected:forwardthisformtoOWCP
Losttimecoveredbyleave,LWOP,orCOP:forwardthisformtoOWCP
FirstAidInjury
FormCA-1
Rev.Apr.1999
19.Employee'sretirementcoverage
FERSCSRS Other,(identify)
InstructionsforCompletingFormCA-1
Completeallitemsonyoursectionoftheform.Ifadditionalspaceisrequiredtoexpl ainorclarifyanypoint,attachasupplemental
statementtotheform.Someoftheitemsontheformwhichmayrequirefurtherclarificationareexplainedbelow.
Employee
(Orpersonactingontheemployees'behalf)
15)ElectionofCOP/Leave
13)Causeofinjury
Describeindetailhowandwhytheinjuryoccurred.Give
appropriatedetails(e.g.:ifyoufell,howfardidyoufallandin
Ifyouaredisabledforworkasaresultofthisinjuryandfiled
CA-1withinthirtydaysoftheinjury,youmaybeentitledtoreceive
continuationofpay(COP)fromyouremployingagency.COPis
paidforupto45calendardaysofdisability,andisnotcharged
againstsickorannualleave.Ifyouelectsickorannualleave
youmaynotclaimcompensationtorepurchaseleaveused
duringthe45daysofCOPentitlement.
whatpositiondidyouland?)
14)NatureofInjury
Giveacompletedescriptionofthecondition(s)resultingfrom
yourinjury.Specifytherightorleftsideifapplicable(e.g.,
fracturedleftleg:cutonrightindexfinger).
Supervisor
33)Firstdatemedicalcarereceived
Atthetimetheformisreceived,completethereceiptofnoticeof
injuryandgiveittotheemployee.Inadditiontocompleting
items17through39,thesupervisorisresponsibleforobtaining
thewitnessstatementinItem16andforfillinginthepropercodes
Thedateofthefirstvisittothephysicianlistedinitem31.
36)
Iftheemployingagencycontrovertscontinuationof
pay,statethereasonIndetail.
inshadedboxesa,b,andconthefrontoftheform.Ifmedical
expenseorlosttimeisincurredorexpected,thecompletedform
shouldbesenttoOWCPwithin10workingdaysafteritisreceived.
COPmaybecontroverted(disputed)foranyreason;however,
theemployingagencymayrefusetopayCOPonlyifthe
controversionisbasedupononeoftheninereasonsgiven
below:
Thesupervisorshouldalsosubmitanyotherinformationor
evidencepertinenttothemeritsofthisclaim.
a)Thedisabilitywasnotcausedbyatraumaticinjury.
IftheemployingagencycontrovertsCOP,theemployeeshould
benotifiedandthereasonforcontroversionexplainedtohimor
Theemployeeisavolunteerworkingwithoutpayorfor
nominalpay,oramemberoftheofficestaffofaformer
President;
b)
her.
17)Agencynameandaddressofreportingoffice
TheemployeeisnotacitizenoraresidentoftheUnited
StatesorCanada;
Thenameandaddressoftheofficetowhichcorrespondence
fromOWCPshouldbesent(ifapplicable,theaddressofthe
personnelorcompensationoffice).
Theinjuryoccurredofftheemployingagency'spremisesand
theemployeewasnotinvolvedinofficial"offpremise"duties;
18)Dutystationstreetaddressandzipcode
Theaddressandzipcodeoftheestablishmentwherethe
employeeactuallyworks.
e)
Theinjurywasproximatelycausedbytheemployee'swillful
misconduct,intenttobringaboutinjuryordeathtoselfor
anotherperson,orintoxication;
19)EmployersRetirementCoverage.
Indicatewhichretirementsystemtheemployeeiscoveredunder.
TheinjurywasnotreportedonFormCA-1within30days
followingtheinjury;
30)Wasinjurycausedbythirdparty?
Athirdpartyisanindividualororganization(otherthanthe
injuredemployeeortheFederalgovernment)whoisliablefor
theinjury.Forinstance,thedriverofavehiclecausingan
accidentinwhichanemployeeisinjured,theownerofa
Workstoppagefirstoccurred45daysormorefollowing
theinjury;
Theemployeeinitiallyreportedtheinjuryafterhisorher
employmentwasterminated;or
buildingwhereunsafeconditionscauseanemployeetofall,and
amanufacturerwhosedefectiveproductcausesanemployee's
injury,couldallbeconsideredthirdpartiestotheinjury.
i)
TheemployeeIsenrolledintheCivilAirPatrol,PeaceCorps,
YouthConservationCorps,WorkStudyPrograms,orother
similargroups.
32)Nameandaddressofphysicianfirstproviding
medicalcare
Thenameandaddressofthephysicianwhofirstprovided
medicalcareforthisinjury.Ifinitialcarewasgivenbyanurse
orotherhealthprofessional(notaphysician)intheemploying
agency'shealthunitorclinic,indicatethisonaseparatesheet
ofpaper.
EmployingAgency-RequiredCodes
Boxa(OccupationCode),Boxb(TypeCode),
Boxc(SourceCode),OSHASiteCode
OWCPAgencyCode
Thisisafour-digit(orfourdigitplustwoletter)codeusedby
OWCPtoidentifytheemployingagency.Thepropercodemay
beobtainedfromyourpersonnelorcompensationoffice,orby
contactingOWCP.
TheOccupationalSafetyandHealthAdministration(OSHA)
requiresallemployingagenciestocompletetheseitemswhen
reportinganinjury.ThepropercodesmaybefoundinOSHA
Booklet2014,"RecordkeepingandReportingGuidelines.
g)
c)
d)
f)
h)
FormCA-1
Rev.Apr.1999
BenefitsforEmployeesundertheFederalEmployees'Compensationact(FECA)
TheFECA,whichisadministeredbytheOfficeofWorkers'
CompensationPrograms(OWCP),providesthefollowing
benefitsforjob-relatedtraumaticinjuries:
(4)Vocationalrehabilitationandrelatedserviceswhere
(1)Continuationofpayfordisabilityresultingfromtraumatic,
job-relatedinjury,nottoexceed45calendardays.(Tobe
eligibleforcontinuationofpay,theemployee,orsomeone
actingonhis/herbehalf,mustfileFormCA-1within30days
followingtheinjuryandprovidemedicalevidenceinsupport
ofdisabilitywithin10daysofsubmissionoftheCA-1.Where
theemployingagencycontinue'stheemployee'spay,thepay
mustnotbeinterruptedunlessoneoftheprovision'soutlined
in20CFR10.222apply.
directedbyOWCP.
(5)Allnecessarymedicalcarefromqualifiedmedicalproviders.
Theinjuredemployeemaychoosethephysicianwhoprovides
initialmedicalcare.Generally,25milesfromtheplaceof
injury,placeofemployment,oremployee'shomeisareasonable
distancetotravelformedicalcare.
AnemployeemayusesickorannualleaveratherthanLWOP
whiledisabled.Theemployeemayrepurchaseleaveused
forapprovedperiods.FormCA-7b,availablefromthe
personneloffice,shouldbestudiedBEFOREadecision
ismadetouseleave.
(2)Paymentofcompensationforwagelossaftertheexpiration
ofCOP,ifdisabilityextendsbeyondsuchpoint,orifCOPisnot
payable.IfdisabilitycontinuesafterCOPexpires,FormCA-7,
withsupportingmedicalevidence,mustbefiledwithOWCP.
Toavoidinterruptionofincome,theformshouldbefiledonthe
40thdayoftheCOPperiod.
Foradditionalinformation,reviewtheregulationsgoverning
theadministrationoftheFECA(CodeofFederalRegulations,
Chapter20,Part10)orpamphletCA-810.
(3)Paymentofcompensationforpermanentimpairmentof
certainorgans,members,orfunctionsofthebody(suchas
lossorlossofuseofanarmorkidney,lossofvision,etc.),
orforseriousdefringementofthehead,face,orneck.
PrivacyAct
InaccordancewiththePrivacyActof1974,asamended(5U.S.C.552a),youareherebynotifiedthat:(1)TheFederalEmployees'
CompensationAct,asamendedandextended(5U.S.C.8101,etseq.)(FECA)isadministeredbytheOfficeofWorkers'Compensation
ProgramsoftheU.S.DepartmentofLabor,whichreceivesandmaintainspersonalinformationonclaimantsandtheirimmediatefamilies.(2)
InformationwhichtheOfficehaswillbeusedtodetermineeligibilityforandtheamountofbenefitspayableundertheFECA,andmaybe
verifiedthroughcomputermatchesorotherappropriatemeans.(3)InformationmaybegiventotheFederalagencywhichemployedthe
claimantatthetimeofinjuryinordertoverifystatementsmade,answerquestionsconcerningthestatusoftheclaim,verifybilling,andto
considerissuesrelatingtoretention,rehire,orotherrelevantmatters.(4)InformationmayalsobegiventootherFederalagencies,other
governmententities,andtoprivate-sectoragenciesand/oremployersaspartofrehabilitativeandotherreturn-to-workprogramsandservices.
(5)Informationmaybedisclosedtophysiciansandotherhealthcareprovidersforuseinprovidingtreatmentormedical/vocational
rehabilitation,makingevaluationsfortheOffice,andforotherpurposesrelatedtothemedicalmanagementoftheclaim.(6)Informationmaybe
giventoFederal,stateandlocalagenciesforlawenforcementpurposes,toobtaininformationrelevanttoadecisionundertheFECA,to
determinewhetherbenefitsarebeingpaidproperly,includingwhetherprohibiteddualpaymentsarebeingmade,and,whereappropriate,to
pursuesalary/administrativeoffsetanddebtcollectionactionsrequiredorpermittedbytheFECAand/ortheDebtCollectionAct.(7)
Disclosureoftheclaimant'ssocialsecuritynumber(SSN)ortaxidentifyingnumber(TIN)onthisformismandatory.TheSSNand/orTIN),and
otherinformationmaintainedbytheOffice,maybeusedforidentification,tosupportdebtcollectioneffortscarriedonbytheFederal
government,andforotherpurposesrequiredorauthorizedbylaw.(8)Failuretodiscloseallrequestedinformationmaydelaytheprocessing
Note:ThisnoticeappliestoallformsrequestinginformationthatyoumightreceivefromtheOfficeinconnectionwiththe
processingandadjudicationoftheclaimyoufiledundertheFECA.
ReceiptofNoticeofInjury
ThisacknowledgesreceiptofNoticeofInjurysustainedby
*U.S.GPO:1999-454-845/12704
oftheclaimorthepaymentofbenefits,ormayresultinanunfavorabledecisionorreducedlevelofbenefits.
FormCA-1
Rev.Apr.1999
(Nameofinjuredemployee)
Whichoccurredon(Mo.,Day,Yr.)
At(Location)
SignatureofOfficialSuperior
Title
Date(Mo.,Day,Yr.)
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Ca 1 CA - (AFGE Local 1040 Members)

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Completed 15 July 2020

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