Ca-17 Form - Duty Status Report
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1
2U.S. Department of Labor
Duty Status Report
Employment Standards Administration
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Office of Workers' Compensation Programs
This form is provided for the purpose of obtaining a duty status report for the employee named below. This request
OMB No. 1215-0103
Expires: 10-31-08
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
OWCP File Number
required to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom
(If known)
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 A - Supervisor: Complete this side and refer to physician
SIDE B - Physician: Complete this side
1. Employee's Name (Last, first, middle)
8. Does the History of Injury Given to You by the Employee
Correspond to that Shown in Item 5?
Yes
No (If not, describe)
3. Social Security No.
2. Date of Injury (Month, day, yr.)
4. Occupation
9. Description of Clinical Findings
5. Describe How the Injury Occurred and State Parts of the Body Affected
11. Other Disabling Conditions
10. Diagnosis Due to Injury
12. Employee Advised to Resume Work?
6. The Employee Works
Yes, Date Advised
No
/
/
Days Per Week
Hours Per Day
13. Employee Able to Perform Regular Work Described on Side A?
7. Specify the Usual Work Requirements of the Employee. Check
Yes, If so
Full-Time
or
Part-Time
Hrs Per Day
Whether Employee Performs These Tasks or is Exposed
No, If not, complete below:
Continuously or intermittently, and Give Number of Hours.
Continuous
Intermittent
Activity
Continuous Intermittent
#Ibs.
#Ibs.
#lbs.
#Ibs.
a. Lifting/Carrying:
Hrs Per Day
Hrs Per Day
State Max Wt.
b. Sitting
Hrs Per Day
Hrs Per Day
Hrs Per Day
Hrs Per Day
c. Standing
d. Walking
Hrs Per Day
Hrs Per Day
Hrs Per Day
H rs Per Day
e. Climbing
Hrs Per Day
f. Kneeling
Hrs Per Day
g. Bending/Stooping
Hrs Per Day
H rs Per Day
h. Twisting
Hrs Per Day
Hrs Per Day
i. Pulling/Pushing
Hrs Per Day
Hrs Per Day
Hrs Per Day
Hrs Per Day
j. Simple Grasping
k. Fine Manipulation
Hrs Per Day
H rs Per Day
(includes keyboarding)
l. Reaching above
Hrs Per Day
H rs Per Day
Shoulder
m. Driving a Vehicle
(Specify)
Hrs Per Day
Hrs Per Day
n. Operating Machinery
Hrs Per Day
Hrs Per Day
(Specify)
range in
range in
degrees
o. Temp. Extremes
degrees
F
F
Hrs Per Day
Hrs Per Day
p. High Humidity
q. Chemicals, Solvents,
Hrs Per Day
H rs Per Day
etc. (Identify)
r. Fumes/Dust (identify)
Hrs Per Day
H rs Per Day
dBA
dBA
s. Noise (Give dBA)
Hrs Per Day
H rs Per Day
14. Are Interpersonal Relations Affected Because of a Neuropsychiatric
t. Other (Describe)
Condition? (e.g. Ability to Give or Take Supervision, Meet Deadlines,
etc.)
Yes
No (Describe)
15. Date of Examination
16. Date of Next Appointment
17. Specialty
18. Tax Identification Number
19. Physician's Signature
20. Date
Form CA-17
Rev. Jan. 1997
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