Fillable Ca-17 DOL-ESA Forms

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Ca-17 DOL-ESA Forms

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U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Duty Status Report
This form is provided for the purpose of obtaining a duty status report for the employee named below. This request
does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any
previous authorization issued in this case. This request for information is authorized by law (5 USC 8101 et seq.) and is
required to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom
of Information Act, the Privacy Act of 1974 and the OMB Cir. A-108. Persons are not required to respond to this
collection of information unless it displays a currently valid OMB control number.
SIDE B - Physician: Complete this side
SIDE A - Supervisor: Complete this side and refer to physician
1. Employee's Name (Last, first, middle)
3. Social Security No.
2. Date of Injury (Month, day, yr.)
11. Other Disabling Conditions
10. Diagnosis Due to Injury
i. Pulling/Pushing
n. Operating Machinery
o. Temp. Extremes
dBA dBA
s. Noise (Give dBA)
Hrs Per Day H
rs Per Day
14. Are Interpersonal Relations Affected Because of a Neuropsychiatric
Condition? (e.g. Ability to Give or Take Supervision, Meet Deadlines,
t. Other (Describe)
etc.)
Yes
No (Describe)
Form CA-17
Rev. Jan. 1997
e. Climbing
(Specify)
range in
degrees F
OMB No. 1215-0103
Expires: 09-30-2011
OWCP File Number
(If known)
8. Does the History of Injury Given to You by the Employee
Correspond to that Shown in Item 5?
No (If not, describe)
Yes
9. Description of Clinical Findings
4. Occupation
5. Describe How the Injury Occurred and State Parts of the Body Affected
6. The Employee Works
Hours Per Day
Days Per Week
7. Specify the Usual Work Requirements of the Employee. Check
Whether Employee Performs These Tasks or is Exposed
Continuously or intermittently, and Give Number of Hours.
12. Employee Advised to Resume Work?
Yes, Date Advised
No
/ /
13. Employee Able to Perform Regular Work Described on Side A?
Part-Time
Full-Time or
Yes, If so
Hrs Per Day
No, If not, complete below:
Activity
Continuous
Intermittent
Continuous
Intermittent
a. Lifting/Carrying:
State Max Wt.
#Ibs.
#Ibs.
Hrs Per Day
#lbs.
#Ibs.
Hrs Per Day
b. Sitting
Hrs Per Day
Hrs Per Day
c. Standing
Hrs Per Day
Hrs Per Day
d. Walking
Hrs Per Day H
rs Per Day
Hrs Per Day H
rs Per Day
f. Kneeling
Hrs Per Day
Hrs Per Day
g. Bending/Stooping
Hrs Per Day H
rs Per Day
h. Twisting
Hrs Per Day
Hrs Per Day
Hrs Per Day
Hrs Per Day
j. Simple Grasping
Hrs Per Day
Hrs Per Day
k. Fine Manipulation
(includes keyboarding)
Hrs Per Day H
rs Per Day
l. Reaching above
Shoulder
Hrs Per Day H
rs Per Day
m. Driving a Vehicle
(Specify)
Hrs Per Day H
rs Per Day
Hrs Per Day
Hrs Per Day
range in
degrees F
p. High Humidity
Hrs Per Day
Hrs Per Day
q. Chemicals, Solvents,
etc. (Identify)
Hrs Per Day H
rs Per Day
r. Fumes/Dust (identify)
Hrs Per Day H
rs Per Day
15. Date of Examination
16. Date of Next Appointment
17. Specialty
18. Tax Identification Number
19. Physician's Signature
20. Date
Reset
Print
INSTRUCTIONS FOR COMPLETING DUTY STATUS REPORT (CA-17)
Complete Side A and refer the form to the physician to complete Side B.
Fill in the address of the Employing Agency and the appropriate OWCP
District Office in the spaces below. Enter the OWCP file number in the
top right corner.
SUPERVISOR:
Complete Side B, sign and return to the employing agency within 2 days
to prevent interruption of the employee's income. Fill in your name and
address.
PHYSICIAN:
Medical Facility Name and Address
Send Original Report to:
Employing Agency Address
Send a Copy of This Report to:
OFFICE OF WORKERS' COMPENSATION PROGRAMS
CERTIFICATION:
BY SIGNING BLOCK 19 ON THE FRONT OF THIS FORM, THE PHYSICIAN
CERTIFIES AS FOLLOWS:
I CERTIFY THAT ALL THE STATEMENTS IN RESPONSE TO THE
QUESTIONS ASKED ON THIS FORM CA-17 ARE TRUE, COMPLETE AND
CORRECT TO THE BEST OF MY KNOWLEDGE. FURTHER, I UNDERSTAND
THAT ANY KNOWINGLY FALSE OR MISLEADING STATEMENT, OR
MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACT, MAY
SUBJECT ME TO FELONY CRIMINAL PROSECUTION.
I FURTHER UNDERSTAND THAT THIS REQUEST DOES NOT CONSTITUTE
AUTHORIZATION FOR PAYMENT OF MEDICAL EXPENSES BY THE
DEPARTMENT OF LABOR, NOR DOES IT INVALIDATE ANY PREVIOUS
AUTHORIZATION ISSUED IN THIS CASE.
Public Burden Statement
We estimate that it will take an average of 5 minutes to complete this collection of information, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, send them to the OWCP, U.S. Department of Labor, Room S-3229, 200
Constitution Avenue, N.W., Washington, D.C. 20210.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402
188-099
2000
G. P. 0.
-
-
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Ca-17 DOL-ESA Forms

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Completed 3 July 2020

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