Transcription of Federal Employee's Notice of Traumatic Injury and …
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Federal Employee's Notice of Traumatic Injury and …
FederalEmployee' eofWorkers'CompensationProgramsEmployee: Pleasecompleteallb (SupervisororCompensationSpecialist):Com pleteshadedboxesa,b, (Last,First,Mid dle) njuryLevel 'shomemailingaddress(inc ludestreet address, city,state,andZIPcode) ( ,Mai nPostOfficeBldg.,12th&Pine) ' (Describewhathappenedandwhy) (Identifybot ht heinjuryandthepartofbody, ,fractureoflef tleg) ,underpenaltyoflaw,thattheinjurydescribe dabovewassustainedinperformanceofdutyasa nemployeeoftheUni tedStatesGovernmentandthatitwasnotcaused bymywill fulmisconduct,intenttoinjurem ysel foranotherperson,norbymyi ntoxi cati ai mm edicaltreatm ent,i fneeded,andthefoll owi ng,ascheckedbel ow,whi l edi sabledforwork:a. Conti nuati onofregul arpay(COP)nottoexceed45daysandcom pensationforwagel ossi fdi sabil i tyforworkconti yclai mi sdenied,Iunderstandthattheconti nuati ono fm yregularpayshal lbechargedtosi ckorannualleave, Si ckand/orA nnualLeaveIherebyauthorizeanyphysicianor hospital(oranyotherperson,institution,co rporation,orgovernmentagency) ,Offic eofWorkers'CompensationPrograms(ortoit sofficialrepresentative).
Title: Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation Author: OASAM/OWCP Created Date: 1/24/2013 4:49:59 PM
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