Fillable Dol-Owcp Forms - Postal Reporter (Page 3 of 4) in pdf

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. 10.102 and 20 C.F.R.

10.103.

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.

EMPLOYEE

(or person acting on the employee's behalf) - Complete sections 1 through 7 as directed and submit the form to

the employee's supervisor.

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

A third party is an individual or organization (other than the injured employee or the Federal

made against 3rd party?

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.

8. Additional Pay

''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.

11. Continuation of pay (COP)

If the injury was not a traumatic injury reported on Form CA-1, this item does not apply.

received

14. Remarks

This space is used to provide relevant information which is not present else- where on the form.

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.

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

CA-7 Page 3 (Rev.05-11)

Dol-Owcp Forms - Postal Reporter Page 3

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