CA-1 - Federal Employee's Notice of Traumatic …

1 HBK EL-505, injury COMPENSATION, DECEMBER 1995 FORMS359 OWCP form CA-1 InstructionsFederal Employees Notice of Traumatic injury and Claim for Continuationof Pay/CompensationSummaryPurposeOfficial Notice to the employee s supervisor and to the OWCP that a traumaticinjury has been sustained (or it is alleged to have been sustained).General Procedures and Preparation Responsibilitiesa. The employee , or the employee s representative, desiring to report an injuryor claim benefits under the FECA, is provided a CA-1 by his or The employee or the representative completes items 1 15 and submits theform to his or her : When emergency medical care is required, the form may becompleted after medical care has been The supervisor, after reviewing the employee s portion of the form foraccuracy and completeness, completes and returns the attached receipt tothe employee . At this time, the supervisor should advise the employee if theclaim will be controverted; if there is doubt, the employee should be advisedthat a decision to controvert will be made after an investigation is The supervisor completes the supervisor s portion of the form .

2 The controloffice or point completes items 23 The supervisor prepares form 1769, Accident supervisor submits the completed form and witness statement(s), ifavailable, and a copy of the form 1769, to either the control office or thecontrol employee is required to submit the claim within 2 working days following theinjury. Statutory time requirements are met if filed within 3 years. To be eligiblefor COP, the claim must be filed within 30 calendar days following the day ofinjury. OWCP requires that the completed CA-1 be submitted to the office within10 working days following receipt of the claim from the EL-505, injury COMPENSATION, DECEMBER 1995 FORMS360 InstructionsProviding the FormWhen an employee desires to report a Traumatic injury , and the description ofhow the injury took place fits an on-the-job Traumatic injury , the CA-1 will beprovided to the employee for his or her completion. When the employee is notphysically or mentally capable of completing the form , the employee srepresentative completes it.

3 A supervisor may complete the form for theemployee only if it is absolutely the CA-1 is issued, the supervisor should provide instructions as to what isrequired. Basically, the employee should be advised that Items 1 15 must becompleted with detailed entries. The employee must be advised that either blocka or block b of Item 15 must be selected even if no immediate disability isindicated. The employee must also be advised of the right to elect eithercontinuation of pay or sick or annual leave in the event that disability is realizedas follows:a. An injured employee may have the option to elect sick or annual leave for theperiod of disability. Pay that is attributable to the period of such leave issubject to taxes and all other usual payroll deductions. Leave is limited to theamount that has been earned. An employee who elects to take sick or annualleave during the 45-day period in which continuation of pay is available, is notentitled to buy back that leave with compensation payments he or she laterreceives.

4 However, if an employee elects to use sick or annual leave during aperiod of disability and later decides that the use of COP is desired, COP willbe paid retroactively, if requested within 1 An injured employee may have the option to elect continuation of pay for thefirst 45 calendar days of disability. Such pay is subject to taxes and all otherappropriate payroll the completed CA-1 is submitted to the supervisor by the employee , or bythe employee s representative, the supervisor must review the form for accuracy,detail, and completeness. Corrections should be made by the employee orrepresentative, if necessary. All changes should be initialed by the employee : The date in Item 11 must be the date the completed CA-1 was submittedto the supervisor or another responsible USPS management Receipt of Notice of injury is required to be presented to the employee or therepresentative at the time the form is submitted to management. Such receipt isthe evidence an employee needs to prove not only that a claim was submitted inthe event that the original documents are lost, but also to show the timeliness ofthe claim s the receipt is completed, it is to be completed in its entirety.

5 At this time theemployee or the representative should be advised that the receipt should beretained in a safe place to ensure that it is available in the EL-505, injury COMPENSATION, DECEMBER 1995 FORMS361 Filing and Distributiona. If the claim is not reported to the OWCP:(1) File the original of CA-1 in the employee s OMF; use a sealed envelope ifno OMF is available.(2) Place a copy in the IC claim file notated Original in OMF. (3) Send a copy to the safety office, after deleting any sensitive If the claim is reported to the OWCP:(1) Forward an original copy of CA-1 to the district OWCP by either a USPS injury compensation control office or the office or installation designatedto correspond with the OWCP.(2) Send a copy to the IC claim file.(3) Send a copy to the safety Aid InjuriesWhen either the initial medical visit or one-time follow-up medical care is providedto confirm full recovery following the day of injury during the employee s regularlyscheduled workhours, the claim must be reported to the OWCP.

6 This applies tomedical care provided either on or off postal premises and includes treatment byboth postal medical units and contract physicians. First aid injuries will bediscussed in greater detail later on in this : If the CA-1 is complete and other materials, such as medical reports andwitness statements are not available, or if a controversion package iscontemplated, the CA-1 should be dispatched to the OWCP with Item 38annotated accordingly, or with a cover letter explaining the s Portion of the form , Items 1 15 Item 1 through 15 will be completed by either the injured employee or by his orher : The shaded blocks, a, b, and c will be completed by either the ICControl Office or control following instructions should be followed when completing the employee sportion of the form ; Items not listed are Insert appropriate designation, , PS/10; EAS/16/8, If Other in Item 8 is checked, have employee submit related information, , identity and relationship. If no dependents, enter None.

7 HBK EL-505, injury COMPENSATION, DECEMBER 1995 FORMS362 Check appropriate box(es). If other is checked, have employee submitrelated information on an attachment; , identify children aged 18 through22 who are either full-time students or who are unable to care for themselves,identify dependent parents, brothers, sister, grandparents or note that married children cannot be claimed as dependents evenwhen residing with the parent. Also, if child support is paid for children livingelsewhere due to a divorce or separation, a copy of the court order is to location where injury occurred. If off postal premises, identify the streetaddress, location on property or street, etc. If on postal premises, identify thebuilding and/or room, location, work area, column, grid, parking lot location,stairwell, Month, day, year and time of injury . If injury developed over a period of timeduring a single tour, enter the time Date of Notice is the day on which the claim form is The title requested is the formal title of the employee s position within thePostal Service.

8 This Item will be used to identify the code to be inserted intoshaded block a. Claimant s title and either FTR, PTF, PTR, Casual, TE, EAS,PCES, or other Description of how and why the injury was sustained. If the space isinsufficient, use continuation Identification of the part of the body injured and type of injury such as abruised right heel, strained lower back, etc. It is important that the employeeidentify all parts of the body injured to preclude later The claimant must check either block a or b even if there is no expected timeloss. Prior to making a selection, the claimant must be advised of the COPbenefit versus taking personal leave. This selection must be an informedselection. Check for signature and understanding of penalty Witness names and statements are obtained by the supervisor. If only onewitness, have him or her complete; if insufficient space, use an multiple witnesses, list names in Item 16 with notation to see no witnesses, have claimant enter such and : Supervisor should obtain witness statement Supervisor s Portion of the form , Items 17 38 Items 17 through 38 will be completed by the immediate supervisor of the injuredemployee or by the injury Compensation Control Office or Control Explanation17.

9 Per instructions on the form and the USPS policy, this is the identification andaddress of the control office authorized to communicate with the districtHBK EL-505, injury COMPENSATION, DECEMBER 1995 FORMS363 OWCP. This is the office authorized to receive correspondence from theOWCP. This is not always the installation in which the injured employee isemployed. See Item : The OSHA Site Code block is not required at this Enter the name and full address of the installation in which the injuredemployee is employed. This could be an associate office, a branch, a station,a repair facility, a VMF, a. If claimant has fixed duty hours, enter start and end If claimant has variable or flexible hours, enter Variable following Regular Work Hours. 20. a. If the claimant has a fixed workday schedule, check the If claimant has a rotating (carrier), or flexible schedule or a variableworkday schedule, enter either Variable or Rotating and enter Weekof injury then check the days worked during the week of Enter the date of injury .

10 If this item does not agree with item 10, enter reasonin item 34 or on an This is the date that the claim form was received either by the immediatesupervisor or by a management representative. This item is significant todetermine eligibility for COP, , was the claim form submitted within 30days after the the event that the supervisor submits the CA-1 to the control office or pointon the day of the injury before medical reports are received to determine theduty status of the claimant, Items 23 26 should be completed by the This item refers to the first tour of duty or date on which the injured employeeeither did not report to work, or stopped work, following the day of injury , dueto disability caused by the Traumatic injury :a. Enter Did Not Stop if employee continued on Enter Did Not Stop if employee missed work only to obtain medical careor therapy no disability time entry will be either the start time of the first tour of duty missed,following the day of injury , or the actual time the employee departed the workarea or installation, following the day of injury , due to disability, not just formedical care or Enter a date only if the claimant enters a leave without pay (LWOP) statusfollowing the day of a.