Federal Employee'S Notice Of Traumatic Injury And Claim For Continuation Of Pay/compensation Form (Page 3 of 4) in pdf

Instructions for Completing Form CA-1

Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental

statement to the form. Some of the items on the form which may require further clarification are explained below.

Employee (Or person acting on the employees' behalf)

15) Election of COP/Leave

13) Cause of injury

Describe in detail how and why the injury occurred. Give

If you are disabled for work as a result of this injury and filed

appropriate details (e.g.: if you fell, how far did you fall and in

CA-1 within thirty days of the injury, you may be entitled to receive

what position did you land?)

continuation of pay (COP) from your employing agency. COP is

paid for up to 45 calendar days of disability, and is not charged

14) Nature of Injury

against sick or annual leave. If you elect sick or annual leave

Give a complete description of the condition(s) resulting from

you may not claim compensation to repurchase leave used

your injury. Specify the right or left side if applicable (e.g.,

during the 45 days of COP entitlement.

fractured left leg: cut on right index finger).

Supervisor

33) First date medical care received

At the time the form is received, complete the receipt of notice of

injury and give it to the employee. In addition to completing

The date of the first visit to the physician listed in item 31.

items 17 through 39, the supervisor is responsible for obtaining

36) If the employing agency controverts continuation of

the witness statement in Item 16 and for filling in the proper codes

pay, state the reason In detail.

in shaded boxes a, b, and c on the front of the form. If medical

expense or lost time is incurred or expected, the completed form

COP may be controverted (disputed) for any reason; however,

should be sent to OWCP within 10 working days after it is received.

the employing agency may refuse to pay COP only if the

controversion is based upon one of the nine reasons given

The supervisor should also submit any other information or

below:

evidence pertinent to the merits of this claim.

a) The disability was not caused by a traumatic injury.

If the employing agency controverts COP, the employee should

The employee is a volunteer working without pay or for

be notified and the reason for controversion explained to him or

nominal pay, or a member of the office staff of a former

her.

President;

17) Agency name and address of reporting office

The employee is not a citizen or a resident of the United

The name and address of the office to which correspondence

States or Canada;

from OWCP should be sent (if applicable, the address of the

personnel or compensation office).

The injury occurred off the employing agency's premises and

the employee was not involved in official "off premise" duties;

18) Duty station street address and zip code

e) The injury was proximately caused by the employee's willful

The address and zip code of the establishment where the

employee actually works.

misconduct, intent to bring about injury or death to self or

another person, or intoxication;

19) Employers Retirement Coverage.

Indicate which retirement system the employee is covered under.

The injury was not reported on Form CA-1 within 30 days

30) Was injury caused by third party?

following the injury;

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

Work stoppage first occurred 45 days or more following

injured employee or the Federal government) who is liable for

the injury;

the injury. For instance, the driver of a vehicle causing an

accident in which an employee is injured, the owner of a

The employee initially reported the injury after his or her

building where unsafe conditions cause an employee to fall, and

employment was terminated; or

a manufacturer whose defective product causes an employee's

injury, could all be considered third parties to the injury.

i) The employee Is enrolled in the Civil Air Patrol, Peace Corps,

Youth Conservation Corps, Work Study Programs, or other

32) Name and address of physician first providing

similar groups.

medical care

The name and address of the physician who first provided

medical care for this injury. If initial care was given by a nurse

or other health professional (not a physician) in the employing

agency's health unit or clinic, indicate this on a separate sheet

of paper.

Employing Agency - Required Codes

Box a (Occupation Code), Box b (Type Code),

OWCP Agency Code

Box c (Source Code), OSHA Site Code

This is a four-digit (or four digit plus two letter) code used by

The Occupational Safety and Health Administration (OSHA)

OWCP to identify the employing agency. The proper code may

requires all employing agencies to complete these items when

be obtained from your personnel or compensation office, or by

reporting an injury. The proper codes may be found in OSHA

contacting OWCP.

Booklet 2014, "Recordkeeping and Reporting Guidelines.

Form CA-1

Rev. Apr. 1999

Federal Employee'S Notice Of Traumatic Injury And Claim For Continuation Of Pay/compensation Form Page 3

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