Federal Employee'S Notice Of Traumatic Injury And Claim For Continuation Of Pay/compensation Form Page 2
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2
3
4Official Supervisor's Report: Please complete information requested below:
Supervisor's Report
17. Agency name and address of reporting office (include city, state, and zip code)
OWCP Agency Code
OSHA Site Code
ZIP Code
18. Employee's duty station (Street address and ZIP code)
19. Employee's retirement coverage
CSRS
FERS
Other, (identify)
20. Regular
21. Regular
a.m.
a.m.
work
work
hours From:
To:
schedule
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
p.m.
p.m.
22. Date
Mo.
Day
Yr.
23. Date
Mo.
Day
Yr.
24. Date
Mo.
Day
Yr.
a.m.
of
notice
stopped
Injury
received
work
Time:
p.m.
25. Date
Mo.
Day
Yr.
26. Date
Mo.
Day
Yr.
27. Date
Mo.
Day
Yr.
a.m.
pay
45 day
returned
stopped
period began
to work
Time:
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
31. Name and address of third party (Include city, state, and ZIP code)
by third party?
Yes
No
(If "No,"
go to
item 32.)
32. Name and address of physician first providing medical care (Include city, state, ZIP code)
33. First date
Mo.
Day
Yr.
medical care
received
34. Do medical
Yes
No
reports show
employee is
disabled for work?
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,
Rev. Apr. 1999
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