Fillable Ca-7a CA-7a, Time Analysis Form

Fill Online, Printable, Fillable, Blank Ca-7a CA-7a, Time Analysis Form Form

Use Fill to complete blank online AFGE LOCAL 1040 MEMBERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ca-7a CA-7a, Time Analysis Form

On average this form takes 20 minutes to complete

The Ca-7a CA-7a, Time Analysis Form form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 79 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your AFGE Local 1040 Members forms online.

BROWSE AFGE LOCAL 1040 MEMBERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Time Analysis Form
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Employee Statement - Please carefully read instructions on reverse before filling out this form.
3. OWCP File Number
2. SSN
1. Name of Employee: (Last, First, Middle)
4. Period Covered by This Form:
5. Total Hours Claimed
for LWOP:
To:
From:
for Leave BuyBack
6.
In ''Type of Leave Used'' column, use codes "S" = Sick, "A" = Annual, "O" = Other. If Compensation is claimed for
date, indicate "Yes'' in ''Compensation Claimed'' column.
Type of
Number of Hours
Compensation
Reason for Leave Use/Remarks
(e.g., doctor visit, therapy, etc.)
Leave
Claimed?
Date(s)
Leave
Used
Hol
LWOP
Worked
Signature of Claimant
Date Signed
7. Agency Statement/Certification: I certify the above is accurate, except as follows:
Date SignedSignature of Agency Official
Form CA 7a
June 1996
Totals
Reset
Print
Instructions for Completing Form CA-7A
Time Analysis
General: This form is used when claiming FECA compensation, including repurchase of paid leave.
It must be used when claiming compensation for more than one consecutive period of leave.
Instructions for Employee:
Blocks 1, 2, and 3: Self-explanatory.
Block 4: Indicate beginning and ending dates covered by this form. These must be the same as on
Forms CA-7 and CA-7b.
Block 5: If claiming compensation for any dates detailed in block 4, state total number of hours claimed
for leave without pay and total number of hours of leave. This should be at least 10 hours
unless this is your final claim.
Block 6:
1st Column:
Show full date.
2nd Column:
For each date noted in column 1, state "Y" if you are claiming compensation
for that date and "N'' if you are not.
3rd, 4th,
5th and 6th
Show the number of hours of LWOP, number of hours worked, paid
holiday hours, and number of hours of paid leave.
Columns:
7th Column:
Using the legend provided, indicate the type of leave used.
8th Column:
State the reason you were off work. For each date for which compensation
is claimed, there must be medical evidence supporting entitlement.
Sign and Date Form and Submit to the Appropriate Agency Official.
Instructions for Employing Agency:
Block 7: Verify accuracy of hours and status for each date listed. If challenging entitlement for any date,
attempt to resolve discrepancies prior to submitting claim to OWCP. If discrepancy cannot be
resolved, indicate the specific basis for the challenge in the space provided.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Ca-7a CA-7a, Time Analysis Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document