Federal Employee'S Notice Of Traumatic Injury And Claim For Continuation Of Pay/compensation Form

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Federal Employee's Notice of
U.S. Department of Labor
Traumatic Injury and Claim for
Employment Standards Administration
Continuation of Pay/Compensation
Office of Workers' Compensation Programs
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
6. Grade as of
3. Date of birth
Mo. Day Yr.
4. Sex
5. Home telephone
date of injury
Level
Step
Male
Female
7. Employee's home mailing address (Include city, state, and 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
Time
11. Date of this notice
12. Employee's occupation
a.m.
Mo. Day Yr.
Mo. Day Yr.
p.m.
13. Cause of injury (Describe what happened and why)
a. Occupation code
14. Nature of injury (Identify both the injury and the part of body, e.g., fracture of left leg)
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 i ntoxi cati on. I hereby cl ai m m edical treatm ent, i f needed, and the foll owi ng, as checked bel ow, whi l e di sabled for work:
a. Conti nuati on of regul ar pay (COP) not to exceed 45 days and com pensation for wage l oss i f di sabil i ty for work conti nues
beyond 45 days. If m y clai m i s denied, I understand that the conti nuati on of m y regular pay shal l be charged to si ck
or annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.
b. Si ck and/or A nnual 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 Workers' Compensation Programs (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 the 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
Rev. Apr. 1999

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