Fillable Form 10: U.S. Department of Labor Duty Status (Arizona)

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Form 10: U.S. Department of Labor Duty Status (Arizona)

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U.S. Department of Labor
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
OMB No. 1240-0046
Expires: 10-31-2014
OWCP File Number
(If known)
1. Employee's Name (Last, first, middle)
3. Social Security No.
2. Date of Injury (Month, day, yr.)
10
Yes, Date Advised
/ /
No
3. Employee Able to Perform Regular Work Described on Side
Yes, If so
Full-Time or
Part-Time
No, If not, complete below:
i. Pulling/Pushing
n. Operating Machinery
o. Temp. Extremes
dBA dBA
s. Noise (Give dBA)
Hrs Per Day
+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)
CA-17 (Rev. 05-11)
e. Climbing
(Specify)
range in
degrees F
8. Does the History of Injury Given to You by the Employee
Yes
No
Correspond to that Shown in Item 5?
(If not, describe)
9. Description of Clinical Findings
. Diagnosis Due to Injury
11. Other Disabling Conditions
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?
1 A?
Hrs Per Day
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
Hrs 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
Hrs Per Day
m. Driving a Vehicle
(Specify)
Hrs Per Day
Hrs 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
+rs Per Day
r. Fumes/Dust (identify)
Hrs Per Day
+rs Per Day
15. Date of Examination
16. Date of Next Appointment
17.
19. Physician's Signature
20. Date
Specialty
18. Tax Identification Number
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:
Send a Copy
OFF RAMS
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.
For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402
188-099
2000
G. P. 0.
-
-
CA-17
PAGE 2
(Rev. 05-11)
IF YOU HAVE A SUBSTANTIALLY LIMITING PHYSICAL OR MENTAL
IMPAIRMENT, FEDERAL DISABILITY NONDISCRIMINATION LAW GIVES YOU
THE RIGHT TO RECEIVE HELP FROM DFEC IN THE FORM OF
COMMUNICATION ASSISTANCE, ACCOMMODATION AND MODIFICATION TO
AID YOU IN THE FECA CLAIMS PROCESS. FOR EXAMPLE, WE WILL
PROVIDE YOU WITH COPIES OF DOCUMENTS IN ALTERNATE FORMATS,
COMMUNICATION SERVICES SUCH AS SIGN LANGUAGE INTERPRETATION,
OR OTHER KINDS OF ADJUSTMENTS OR CHANGES TO ACCOUNT FOR THE
LIMITATIONS OF YOUR DISABILITY. PLEASE CONTACT OUR OFFICE OR
YOUR CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE.
Employing Agency Address
of This Report to:
ICE OF WORKERS' COMPENSATION PROG
Privacy Act Statement
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.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this
collection of information unless it displays a currently valid OMB control number. Public reporting
burden for this collection of information is estimated to average 5 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. The obligation to
respond to this collection is required to obtain or retain a benefit under 5 U.S.C 8101, et seq. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Office of
Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington,
DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not send the
completed form to this office.
CA-17
PAGE 3
(Rev. 05-11)
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Form 10: U.S. Department of Labor Duty Status (Arizona)

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Completed 27 January 2021

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