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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.

Signature of Agency Official Date Signed Form CA 7a June 1996 Totals. Instructions for Completing Form CA-7A Time Analysis General: This form is used when claiming FECA compensation, including repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.

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