Fillable Federal Employee's Notice of Traumatic Injury and Claim (Department of Labor)

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Federal Employee's Notice of Traumatic Injury and Claim (Department of Labor)

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U.S. Department of Labor
Office of Workers' Compensation Programs
Federal Employee's Notice of Traumatic Injury and
Claim for Continuation of Pay/Compensation
Employee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.
Witness: Complete bottom section 16.
Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.
Employee Data
1. Name of employee (Last, First, Middle)
2. Social Security Number
3. Date of birth Mo. Day Yr.
4. Sex
Male Female
5. Home telephone
6. Grade as of
date of injury
Level Step
7. Employee's home mailing address (include street address, city, state, and ZIP code)
City
State
ZIP Code
8. Dependents
Wife, Husband
Children under 18 years
Other
Description of Injury
9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)
10. Date injury occurred
Mo. Day Yr.
Time
a.m.
p.m.
11. Date of this notice
Mo. Day Yr.
12. Employee's occupation
13. Cause of injury (Describe what happened and why)
14. Nature of injury (identify both the injury and the part of the body, e.g., fracture of left leg)
a. Occupation code
b. Type code c. Source code
OWCP Use - NOI Code
Employee Signature
15. I certify, under penalty of law, that the injury described above was sustained in performance of duty as an employee of the United States
Government and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication. I hereby
claim medical treatment, if needed, and the following, as checked below, while disabled for work:
a. Continuation of regular pay (COP) not to exceed 45 days and compensation for wage loss if disability for work continues beyond 45 days.
If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick or annual leave, or be deemed an
overpayment within the meaning of 5 USC 5584.
b. Sick and/or Annual Leave
I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information
to the U.S. Department of Labor, Office of Worker's Compensation Program (or to its official representative). This authorization also permits any
official representative of the Office to examine and to copy any records concerning me.
Signature of employee or person acting on his/her behalf Date
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.
Have your supervisor complete this receipt attached to this form and return it to you for your records.
Witness Statement
16. Statement of witness (Describe what you saw, heard, or know about this injury)
Name of witness Signature of witness Date signed
Address City
State
ZIP Code
Form CA-1
Revised October 2018
1a. Email address
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or
modifications, please contact OWCP.
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Official Supervisor's Report: Please complete information requested below:
Supervisor's Report
17. Agency name and address of reporting office (include street address, city, state, and ZIP code) OWCP Agency Code
OSHA Site Code
City
State
ZIP Code
18. Employee's duty station (include street address, city, state and ZIP code) City
State
ZIP Code
19 Employee's retirement coverage
CSRS FERS Other, (identify)
20. Regular
work
hours
From:
a.m.
p.m.
To:
a.m.
p.m.
21. Regular
work
schedule
Sun. Mon. Tues. Wed. Thurs. Fri. Sat.
22. Date of Injury
Mo. Day Yr.
23. Date notice received
Mo. Day Yr.
24. Date stopped work
Mo. Day Yr.
Time:
a.m.
p.m.
25. Date pay stopped
Mo. Day Yr.
26. Date 45 day period began
Mo. Day Yr.
27. Date returned to work
Mo. Day Yr.
Time:
a.m.
p.m.
28. Was employee injured in performance of duty?
Yes No (If "No," explain)
29. Was injury caused by employee's willful misconduct, intoxication, or intent to injure self or another?
Yes (If "Yes," explain) No
30. Was injury caused by third party?
Yes
No (If "No," go
to Item 32,)
31. Name and address of third party (include street address, city, state, and ZIP code)
City
State
ZIP Code
32. Name and address of physician first providing medical care (include street address, city, state, ZIP code)
City
State
ZIP Code
33. First date medical
care received
Mo. Day Yr.
34.Do medical reports
show employee is
disabled for work?
Yes No
35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses?
Yes No (If "No," explain)
36. If the employing agency controverts continuation of pay, state the reason in detail.
37. Pay rate when employee stopped work
Per
Signature of Supervisor and Filing Instructions
38. A supervisor who knowingly certifies to any false statement, misrepresentation concealment of fact, etc. in respect of 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 the reverse of this form is true to the best of my knowledge
with the following exception:
Name of supervisor (Type or print)
Signature of supervisor Date
Supervisor's Title Office phone
39. Filing instructions
No lost time and no medical expense: Place this form in employee's medical folder (SF-66-D)
No lost time, medical expense incurred or expected: forward this form to OWCP
Lost time covered by leave, LWOP, or COP: forward this form to OWCP
First Aid Injury
Form CA-1
Revised October 2018
Page 2
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Instructions for Completing Form CA-1
Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental
statement to the form. Some of the items on the form which may require further clarification are explained below.
Employee (or person acting on the employees' behalf)
13) Cause of injury
Describe in detail how and why the injury occurred. Give
appropriate details (e.g.: If you fell, how far did you fall and in
what position did you land?)
14) Nature of injury
Give a complete description of the condition(s) resulting from
your injury. Specify the right or left side if applicable (e.g.,
fractured left leg: cut on right index finger).
15) Election of COP/Leave
If you are disabled for work as a result of this injury and filed
CA-1 within thirty days of the injury, you may be entitled to receive
continuation of pay (COP) from your employing agency. COP is
paid for up to 45 calendar days of disability, and is not charged
against sick or annual leave. If you elect sick or annual leave
you may not claim compensation to repurchase leave used
during the 45 days of COP entitlement.
Supervisor
As the time the form is received, complete the receipt of notice of
injury and give it to the employee. In addition to completing
Items 17 through 39, 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 OWCP within 10 working days after 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) Agency name and address of reporting office
The name and address of the office to which correspondence
from OWCP should be sent (if applicable, the address of the
personnel or compensation office).
18) Duty station street address and zip code
The address and zip code of the establishment where the
employee actually works.
19) Employers Retirement Coverage.
Indicate which retirement system the employee is covered under.
30) Was injury caused by third 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 whose defective product causes an employee's
injury, could all be considered third parties to the injury.
32) Name and address of physician first providing medical
care
The name and address of the physician who first provided
medical care for this injury. If initial care was given by a nurse
or other health professional (not a physician) in the employing
agency's health unit or clinic, indicate this on a separate sheet
of paper.
33) First date medical care received
The date of the first visit to the physician listed in Item 31.
36) If the employing agency controverts continuation of
pay, state the reason in detail.
COP may be controverted (disputed) for any reason; however,
the employing agency may refuse to pay COP only if the
controversion is based upon one of the nine reasons given
below:
a) The disability was not caused by a traumatic injury.
b) The employee is a volunteer working without pay or for
nominal pay, or a member of the office staff of a former
President;
c) The employee is not a citizen or a resident of the United
States or Canada;
d) The injury occurred off the employing agency's premises and
the employee was not involved in official "off premise" duties;
e) The injury was proximately caused by the employee's willful
misconduct, intent to bring about injury or death to self or
another person,k or intoxication;
f) The injury was not reported on Form CA-1 within 30 days
following the injury;
g) Work stoppage first occurred 45 days or more following
the injury;
h) The employee initially reported the injury after his or her
employment was terminated; or
i) The employee is enrolled in the Civil Air Patrol, Peace Corps,
Youth Conservation Corps, Work Study Programs, or other
similar groups.
Form CA-1
Revised October 2018
Page 3
Injured workers should provide an email address when completing
this form. Pursuant to policy established by the Department of Labor,
Office of Workers' Compensation Programs (OWCP), Division of
Federal Employees' Compensation, email communication on case
specific inquiries is not allowed due to security concerns. However,
obtaining claimant email addresses at the point of filing will allow
OWCP to share general, non-case specific information with injured
workers earlier in the claims submission process. As a longstanding
policy and in an effort to protect the identities and personal
information of claimants under the Federal Employees'
Compensation Act, and to allow better tracking of incoming
communications, we do not use two-way email as a primary method
of interaction with claimants and their representatives.)
1a) Email address
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Benefits for Employees under the Federal Employees' Compensation Act (FECA)
The FECA, which is administered by the Office of Workers'
Compensation Programs (OWCP), provides the following
benefits for job-related traumatic injuries:
(1) Continuation of pay for disability resulting from traumatic,
job-related injury, not to exceed 45 calendar days. (To be
eligible for continuation of pay, the employee, or someone
acting on his/her behalf, must file Form CA-1 within 30 days
following the injury and provide medical evidence in support
of disability within 10 days of submission of the CA-1. Where
the employing agency continue's the employee's pay, the pay
must not be interrupted unless one of the provision's outlined
in 20 CFR 10.222 apply.
(2) Payment of compensation for wage loss after the expiration
of COP, if disability extends beyond such point, or if COP is not
payable. If disability continues after COP expires, Form CA-7,
with supporting medical evidence, must be filed with OWCP.
To avoid interruption of income, the form should be filed on the
40th day of the COP period.
(3) Payment of compensation for permanent impairment of
certain organs, members, or functions of the body (such as
loss or loss of use of an arm or kidney, loss of vision, etc.),
or for serious defringement of the head, face, or neck.
(4) Vocational rehabilitation and related services where
directed by OWCP.
(5) All necessary medical care from qualified medical providers.
The injured employee may choose the physician who provides
initial medical care. Generally, 25 miles from the place of
injury, place of employment, or employee's home is a
reasonable distance to travel for medical care.
An employee may use sick or annual leave rather than LWOP
while disabled. The employee may repurchase leave used
for approved periods. Form CA-7b, available from the
personnel office, should be studied BEFORE a decision
is made to use leave.
For additional information, review the regulations governing
the administration of the FECA (Code of Federal Regulations,
Chapter 20, Part 10) or pamphlet CA-810.
Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby 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 health care 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 disclosure 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.
Receipt of Notice of Injury
This acknowledges receipt of Notice of Injury sustained by (Name of injured employee)
Which occurred on (Mo. Day, Yr.)
At (Location)
Signature of Official Superior Title Date (Mo. Day, Yr.)
*U.S. GPO: 1999-454-845/12704
Form CA-1
Revised October 2018
Page 4
Instructions for Completing Form CA-1 Continued
Employing Agency - Required Codes
Box a (Occupation Code), Box b (Type Code),
Box c (Source Code), OSHA Site Code
The Occupational Safety and Health Administration (OSHA)
requires all employing agencies to complete these items when
reporting an injury. The proper codes may be found in OSHA
Booklet 2014, "Recordkeeping and Reporting Guidelines."
OWCP Agency Code
This is a four-digit (or four digit plus two letter) code used by
OWCP to identify the employing agency. The proper code may
be obtained from your personnel or compensation office, or by
contacting OWCP.
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Federal Employee's Notice of Traumatic Injury and Claim (Department of Labor)

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Completed 19 July 2020

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