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CA-7a, Time Analysis Form - DOL

Department of Labor Office of Workers' Compensation ProgramsTime Analysis FormEmployee Statement - Please carefully read instructions on reverse before filling out this Name of Employee: (Last, First, Middle) 2. SSN3. OWCP File Number 4. Period Covered by This form :From:To:5. Total Hours Claimedfor LWOP:for leave BuyBack:6. In "Type of leave Used" column, use codes "S" = Sick, "A" = Annual, "O" = Other. If Compensation is claimed for date, indicate "Yes" in "Compensation Claimed" (s)Compensation Claimed?Number of HoursLWOPW orkedHolLeaveType of leave UsedReason for leave Use/Remarks ( , doctor visit, therapy, etc.)TotalsSignature of ClaimantDate Signed7. Agency Statement/Certification: I certify the above is accurate, except as follows: Date SignedSignature of Agency Official form CA-7a (June 1996) form CA-7a (June 1996) Page 2 Instructions for Completing form CA-7A time AnalysisGeneral: This form is used when claiming FECA compensation, including repurchase of paid leave .

CA-7a, Time Analysis Form Subject: This form is used when claiming FECA compensation, including repurchase of leave. Keywords: CA7a, CA-7a, repurchase of leave, leave repurchase, buyback, buy-back Created Date: 7/26/2002 11:58:03 AM

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