Form Ca-3 - Report Of Termination Of Disabilty And/or Payment
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1
2Report of Termination of Disabilty
U.S. Department of Labor
and/or Payment
Employment Standards Administration
Office of Workers’ Compensation Programs
Part - A General
1. Name of Injured Employee (last, first, middle)
2. Social Security Number
3. OWCP File Number
(if known)
4. Department or Agency
5. Bureau or Office
6. Name and Address of Reporting Office (Include ZIP Code)
7. Date and Hour of
8. Date and Hour Stopped
9. Date and Hour Pay
10. Date and Hour Returned
Injury (Mo., day, year)
Work (Mo., day, year)
Stopped (Mo., day, year)
to Work (Mo., day, year)
AM
AM
AM
AM
PM
PM
PM
PM
11. Employee’s Work Week On
12. Present Pay Rate If Different From That Received At Time Employee Stopped
Return To Duty If Other Than
Work.
Monday Through Friday
a. Base pay
b. Subsistence
c. Quarters
d. Other (Specify)
S
M
T
W
T
F
S
13. Inclusive Dates Employee Received Pay For Any Part of The Period of Absence Because of:
a. Annual Leave
b. Sick Leave
c. Other (Specify)
From:
From:
From:
Through:
Through:
Through:
14. Has Employee’s Work Assignment Been Changed Because of Disability Resulting From This Injury?
Yes
No
If Yes, Describe The Type of Work Employee Is Performing.
15. If Interrupted, Show Dates Deductions For Health
16. If Health Benefits Option Has Changed Since Disability
Benefits and /or Optional Insurance Were Resumed
Began, Show New Code Number and Date of Change
(Mo., day, year)
(Mo., day, year)
Health Benefit
Optional Insurance
Number
Date
17. Remarks:
Part - B Continuation of Pay
18. Inclusive Dates That The Employee’s Regular Pay Con-
19. Show The Gross Dollar Amount Of Regular Pay Which The
tinued During The Period Of Disability. Do not include
Employee Received During The Period Of Disability. Do
period of sick or annual leave (Mo., day, year)
not include pay received for sick leave or annual leave.
From:
Through:
$
20. If Pay Rate Changed During
21. If Pay Rate Changed During The Period Employee Was Receiving Continuation of
The Period Employee Was Receiv-
Pay, Give New Rate
ing Continuation Of Pay, Show
a. Base pay
b. Subsistence
c. Quarters
d. Other (Specify)
The Date of Change (Mo., day,
year)
22. Signature of Supervisor
23. Title and Office Phone Number
24. Date (Mo., day, year)
Form CA-3
Rev. June 1988
EF
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