Forms & Meanings

• Employee was hurt because of a single event or within one workday.
• Employee has up to three years to report an injury.

To be eligible for COP, you must submit a CA-1 within 30 days of the injury (COP last for 45 calendar days). The form must be completed by the injured employee, a witness (if there was one), and the employee’s supervisor.

Guarantees payment to the care provider if the employee requires medical treatment because of a work-related traumatic injury. (The employee only can have a CA-16 form only with a CA-1 Claim).

The injured employee must request this form with in 7 days from their injury. If they request it after seven days, they are no longer entitled to it. When the employee requests it from the supervisor, they have 4 hours to get it to them. This authorization covers non-surgical treatment and continues for up to 60 calendar days from the date of injury. Your supervisor should complete page 1 of Form CA-16. The physician will complete page 2.

A Medical condition developed over more than one workday (Carpal Tunnel, Skin Disease, ETC). If the patient wants to get paid for missed time at work, they must file form CA-7 every two weeks. The patient will not get paid until their claim is approved. Employee has up to three years to report an injury. The form must be completed by the injured employee and the employee’s supervisor.

If for instance an employee has an injured back and they go out of work for awhile and they’re returned back to work and then they have a worsening of that back injury condition, they would claim a recurrence.

• Must have an APPROVED CA-1 or CA-2 claim.
• If a denied claim for a CA-1 or CA-2 occurs there will never be a need for a CA-2a.
• 40% Approval rate / Truly better be a recurrence!
• The form must be completed by the employee and the supervisor.

Information from a doctor forbidding an injured federal employee from carrying out certain activities due to their inherently physically taxing nature.

• If employer does not provide this form we can give the patient a OWCP -5c Form.
• Needs to be addressed every 30 days.
• Needs to be filled out by the injured worker’s supervisor (on the left-hand side) and his/her treating physician (on the right side).

• Evaluate a federal employee’s work capacity due to musculoskeletal conditions.
• If employer does not give employee CA-17 we can provide patient with this form.
• This form needs to be addressed every 30 days.

How to document on what you should do when injured at work.

This medical report is required by OWCP BEFORE payment of compensation for loss of wages can be made to the employee. Recommend this form used in lieu of a narrative medical report issued by the physician. Needs to be attached to the CA-16 and should be completed at the initial office visit. If there are any changes to the treatment plan or diagnosis the doctor should complete a new one at that time. This form is completed by the physician.

When COP runs out and their claim is approved the employee is eligible to fill out a CA-7 (as soon as the claim is approve the COP goes away and a CA-7 is needed). Eligible to be paid up to 4 hours related to getting care for their work injury. Need to select Leave without Pay (LWOP) You will get paid!

The employee shall complete the front of Form CA-7 and submit the form to the employer for completion and transmission to OWCP. The form should be completed as soon as possible, but no more than 14 calendar days after the date pay stops due to the injury or disease.

• If you do not have a dependent you will get compensated 66% and if you do have a dependent you will be compensated 75%.
• Compensation is paid out when you are either completely off work, reduced hours, or if you are attending medical appointments due to your work injury.
• The form must be filled out by the employee’s work agency.

This form is used when claiming Federal Employees’ Compensation Act (FECA) compensation, including repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.

• If their time away from work is intermittent, they need to fill out this form.
• If you are off work you should start filling this out asap. Once your claim is approved the employee can get paid from day one when off of work.
• Needs to be filled out by the employee.

When the employee use their sick or annual leave to cover an injury related absence from work, they may elect to receive compensation instead.

In order for leave to be reinstated, the employee must refund to the agency the difference between the compensation entitlement and the total amount of leave paid by the agency. (Remember, If you do not have a dependent you will get compensated 66% and if you do have a dependent you will be compensated 75%. You will have to pay the difference to get your time back.)

Needs to be filled out by the employee.

Provides medical support for specific conditions.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees Notice of Occupational Disease and Claim for Compensation
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to mark and return with the completed package. The second checklist is for the employee to take to the physician.

Completed by: Employee and employee’s supervisor.

Once OWCP has identified third party claims through the claims process, referral to the Solicitor of Labor (SOL) is made. SOL initiates Forms CA-1108 and CA-1122 to determine the amount of the refund due to the United States out of the proceeds of an action asserted by an injured Federal employee against a liable third party for a compensable injury.

An injured federal employee who receives money or property from a judgment or a settlement of the action, must reimburse the United States for past compensation payments. The formula of the FECA must be used to calculate the reimbursement. States that “the beneficiary, after deducting therefrom the costs of suit and a reasonable attorney’s fee, shall refund to the United States the amount of compensation paid by the United States and credit any surplus on future payments of compensation payable to him for the same injury.” Therefore, to calculate the amount of the refund due, the employee must provide the amount of the settlement received by him or her, the amount of the costs of the suit, and the fees charged by the attorney.

If the amount of the employee’s recovery remaining after certain deductions specified in the statute exceeds the amount of OWCP’s disbursements, the surplus must be credited against future payments of compensation, because the FECA mandates that the employee “shall refund to the United States the amount of compensation paid by the United States and credit any surplus on future payments of compensation.”

Once OWCP has identified third party claims through the claims process, referral to the Solicitor of Labor (SOL) is made. SOL initiates Forms CA-1108 and CA-1122 to determine the amount of the refund due to the United States out of the proceeds of an action asserted by an injured Federal employee against a liable third party for a compensable injury.

An injured federal employee who receives money or property from a judgment or a settlement of the action, must reimburse the United States for past compensation payments. The formula of the FECA must be used to calculate the reimbursement. States that “the beneficiary, after deducting therefrom the costs of suit and a reasonable attorney’s fee, shall refund to the United States the amount of compensation paid by the United States and credit any surplus on future payments of compensation payable to him for the same injury.” Therefore, to calculate the amount of the refund due, the employee must provide the amount of the settlement received by him or her, the amount of the costs of the suit, and the fees charged by the attorney.

If the amount of the employee’s recovery remaining after certain deductions specified in the statute exceeds the amount of OWCP’s disbursements, the surplus must be credited against future payments of compensation, because the FECA mandates that the employee “shall refund to the United States the amount of compensation paid by the United States and credit any surplus on future payments of compensation.”

Used to seek reimbursement for expenses in regard to medical treatment, prescription medication and medical supplies. (Save your receipts!)

• The case must be accepted before the patient seeks any reimbursement.
• The employer will give to the employee. Then the employee will complete and attach any receipts.
• Once completed the patient should mail it directly to the Department of Labor.

Request reimbursement for your transportation/mileage expenses. (Save your receipts!)

• Patient must attach proof of miles and proof of appointments.
• Department of Labor will reimburse up to 100 miles without any prior approval.
• Once completed the patient should mail it directly to the Department of Labor.

To obtain compensation:

• The supervisor will give to the employee, once the employee completes, they will give back to their supervisor and supervisor will submit to the DOL by Ecomp.
• The SF-1199a is the direct deposit form. All these forms should be completed and turned in directly to the agency. The Agency will then complete their portion and process to DOL.