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Ca-7 DOL-ESA Forms

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U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Claim for Compensation
EMPLOYEE PORTION
SECTION 1
Middle
1215-0103First
OMB No.
Last
a. Name of Employee
Expires: 09/30/2011
c. OWCP File Number
b. Mailing Address (Including City State, ZIP Code)
d. Date of Injury
e. Social Security Number
Month Day Year
Compensation is claimed for:
Inclusive Date Range
-
Yes
Go to Section 3
Go to Section 3, and Complete Form CA-7b
Go to Section 3
No
Leave without pay
a.
Yes
No
Leave buy back
b.
YesOther wage loss; specify type,
c.
such as downgrade, loss of
night differential, etc.
If intermittent, complete Form CA-7a,
Time Analysis Sheet
Type:
Schedule Award (Go to Section 4)
d.
You must report all earnings from employment (outside your federal job); include any employment for which you received a salary,
wages, income, sales commissions, piecework, or payment of any kind during the period(s) claimed in Section 2. Include self-employment, involvement
Name and Address of Business:
Yes
ZIP Code
StateCity
Address
Name
No
Go to
section 4
Type of Work:
Dates Worked:
Is this the first CA-7 claim for compensation you have filed for this injury?
Complete Sections 5 through 7 and a Form SF-1199A, "Direct Deposit Sign-up"
Yes
Has there been any change in your dependents, or has your direct deposit information changed, or has there been a claim
filed with U.S. Civil Service Retirement, another federal retirement or disability law, or with the Department of Veterans
Affairs since
your last CA-7 claim?
No
No - Complete Section 7
Yes - Complete Sections 5 through 7 or a new SF-1199A to reflect change(s)
List your dependents (including spouse
):
Living with you?
Date of Birth
Yes No
Relationship
For dependents not
living with you
,
complete
items a and b below.
a. Are you making support payments for a dependent shown above?
Yes
No
ZIP CodeName
StateAddress City
b. Were support payments ordered by a court?
No
Yes
If Yes, attach copy of court order.
a. Was/Will there be a claim made against a 3rd party?
No
Yes
b. Have you ever applied for or received disability benefits from the Department of Veterans Affairs?
Yes
Claim Number
Full Address of VA Office Where Claim Filed
Nature of Disability and Monthly Payment
No
c. Have you applied for or received payment under any Federal Retirement or Disability law?
Yes
Claim Number
Date Annuity Began
Amount of Monthly Payment Retirement System (CSRS, FERS, SSA, Other)
No
I hereby make claim for compensation because of the injury sustained by me while in the performance of my duty for the
United States. I certify that the information provided above is true and accurate to the best of my knowledge and belief.
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain
compensation as provided by the FECA, 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. In addition, a felony conviction will
result in termination of all current and future FECA benefits.
Employee's Signature
Date (Mo., day, year)
Form CA-7
Rev. June 2005
No
SECTION 3
SECTION 7
SECTION 4
SECTION 5
SECTION 6
SECTION 2
If Yes, support payments are made to:
E-Mail Address (Optional)
(
)
( )
Name
Social Security #
/
/
/ /
/ /
f. Telephone No./FAX No.
From
Intermittent?
To
CSRS
FERS
OtherSSA
in business enterprises, as well as service with the military forces. Fraudulent concealment of employment or failure to report income may result in
forfeiture of compensation benefits and/or criminal prosecution.
Have you worked outside your federal job for the period(s) claimed in Section 2
?
Reset
Print
Employing Agency Portion
For subsequent claims, complete sections 12 through 15 only.
Show Pay Rate as of
SECTION 8
Additional Pay
Additional Pay Additional Pay
Base PayDate of Injury:
Type
Type
Type
$ $ $
perper
per per
Date:
$
Step:
Date Employee Stopped Work:
Type
Type Type
perper
per
per
$
Date: $ $
$
Step:
Grade:
Additional pay types include, but are not limited to: Night Differential (ND), Sunday Premium (SP), Holiday Premium (HP), Subsistence
a. Does employee work a fixed 40-hour per week schedule?
SECTION 9
No
(SUB), Quarter (QTR), etc. (List each separately)
T
TH
M
W F
S
S
1. If Yes, circle scheduled days:
FOR EXAMPLE ONLY
S
M T W TH F
S
WEEK 1
5/20
5/14 to
to
WEEK
5/21
5/27
From
to
From
to
Yes Nob. Did employee work in position for 11 months prior to injury?
Yes NoIf No, would position have afforded employment for 11 months but for the injury?
On date pay stopped, was employee enrolled in:
c. Optional Use Insurance?
Health Benefits under
the FEHBP?
No
Yes Class
(D-Z only)
No Yes Code
d. A Retirement System?
No Yes Plan
b. Basic Life Insurance?
(Specify CSRS, FERS, Other)
No Yes
Continuation of Pay (COP) Received (Show inclusive dates):
Yes Complete Time
Analysis Sheet, Form CA-7a
Intermittent?
To
From
No
Show pay status and inclusive dates for period(s) claimed:
Intermittent?
If intermittent, complete Form
CA-7a, Time Analysis
Sheet.
To
Sick Leave From Yes
No
To
Annual Leave From
Yes
No
To
YesLeave without Pay From
No
If leave buy back, also submit
completed Form CA-7b.
To
Work From
Yes
No
SECTION 13
Yes
No
Did employee return to work?
If Yes, date
If returned, did employee return to the pre-date-of-injury job, with the same number of hours and the same duties?
Yes
No If No, explain:
SECTION 14
Remarks:
An employing agency official who knowingly certifies to any false statement, misrepresentation, or concealment of fact,
with respect to 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 this form is true to the best of my knowledge, with any
exceptions noted in Section 14, Remarks, above.
Signature
Title
Date
(
Agency Official)
Name of Agency
If OWCP needs specific pay information, the person who should be contacted is:
Name
Title
Telephone No.
Fax No.
-
E-Mail Address
For first CA-7 claim sent, complete sections 8 through 15.
2. If No, show scheduled hours for the two week pay period in which work stopped. Circle the day that work stopped.
Yes
6
SECTION 10
a.
SECTION 11
SECTION 12
SECTION 15
(
)
From
Grade:
From
/ /
/ /
S
M
T
W TH
F
S
8
4
6
8 6 6
4
/ / / /
/ /
/ /
/ / / /
/ /
/ /
/ /
/ /
/ /
/ /
( )
Date Claim Form Recieved from Employee
/ /
WEEK 1
INSTRUCTIONS FOR COMPLETING FORM CA-7
If the employee does not quality for continuation of pay (for 45 days), the form should be completed and filed with
the OWCP as soon as pay stops. The form should also be submitted when the employee reaches maximum
improvement and claims a schedule award. If the employee is receiving continuation of pay and will continue to be
disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day period.
The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made.
Collection of this information is required to obtain a benefit and is authorized by 20 C.F.R.10.106.
(or person acting on the employee's behalf) - Complete sections 1 through 7 as directed and
submit the form to the employee's supervisor.
EMPLOYEE
SUPERVISOR (or appropriate official in the employing agency) - Complete sections 8 through 15 as directed
and promptly forward the form OWCP.
EXPLANATIONS - Some of the items on the form which may require further clarification are explained below:
Section Number
Explanation
2d. Schedule Award
Schedule awards are paid for permanent impairment to a member or function
of the body.
5. List your dependents Your wife or husband is a dependent if he or she is living with you. A child is a
dependent if he, or she either lives with you or receives support payments from
you, and he or she: 1) is under 18, or 2) is between 18 and 23 and is a full-time
student, or 3) is incapable of self-support due to physical or mental disability.
6a. Was/will there be a claim
made against 3rd party?
A third party is an individual or organization (other than the injured employee or
the Federal government) who is liable for the injury. For instance, the driver of a
vehicle causing an accident in which an employee is injured, the owner of a
building where unsafe conditions cause an employee to fall, and a manufacturer
who gave improper instructions for the use of a chemical to which an employee
is exposed, could all be considered third parties to the injury.
''Additional Pay'' includes night differential, Sunday premium, holiday premium,
and any other type (such as hazardous duty or ''dirty work'' pay) regularly
received by the employee, but does not include pay for overtime. If the amount
of such pay varies from pay period to pay period (as in the case of holiday
premium or a rotating shift), then the total amount of such pay earned during the
year immediately prior to the date of injury or the date the employee stopped
work (whichever is greater) should be reported.
8. Additional Pay
11. Continuation of pay
(COP) received
If the injury was not a traumatic injury reported on Form CA-1, this item does
not apply.
14. Remarks
This space is used to provide relevant information which is not present
else- where on the form.
Public Burden Statement
Public reporting burden forth is collection of information is estimated to average 13 minutes per response including the 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 estimate or any other aspect of this information collection,
including suggestions for reducing this burden, please send them to the Department of Labor, Office of Workers' Compensation
Programs, 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
The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to
benefits. Furnishing the requested information is required for the claimant 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, as amended (5 U.S.C. 552a). Failure
to furnish the requested information may delay the process, or result in an unfavorable decision or a reduced benefit.
Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are here by
notified that: (1) The Federal Employees' Compensation Act, as amended and extended
(5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U. S .Department of Labor, which receives and maintains personal
information on claimants and their immediate families. (2) Information which the Office
has will be used to determine eligibility for and the amount of benefits payable under the
FECA, and may be verified through computer matches or other appropriate means. (3)
Information may be given to the Federal agency which employed the claimant at the time
of injury in order to verify statements made, answer questions concerning the status of
the claim, verify billing, and to consider issues relating to retention, rehire, or other
relevant matters. (4) Information may also be given to other Federal agencies, other
government entities, and to private-sector agencies and/or employers as part of
rehabilitative and other return-to-work programs and services. (5) Information may be
disclosed to physicians and other healthcare providers for use in providing treatment or
medical/vocational rehabilitation, making evaluations for the Office, and for other
purposes related to the medical management of the claim. (6) Information may be given
to Federal, state and local agencies for law enforcement purposes, to obtain information
relevant to a decision under the FECA, to determine whether benefits are being paid
properly, including whether prohibited dual payments are being made, and, where
appropriate, to pursue salary/administrative offset and debt collection actions required or
permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's
social security number (SSN) or tax identifying number (TIN) on this form is mandatory.
The SSN and/or TIN, and other information maintained by the Office, may be used for
identification, to support debt collection efforts carried on by the Federal government,
and for other purposes required or authorized by law. (8) Failure to disclose all requested
information may delay the processing of the claim or the payment of benefits, or may
result in an unfavorable decision or reduced level of benefits.
Note: This notice applies to all forms requesting information that you might receive
from the Office in connection with the processing and adjudication of the claim you
filed under the FECA.
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Completed 3 July 2020

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