Transcription of CA-17 - Duty Status Report - npmhul310.org
1 HBK EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS447 OWCP Form CA-17 InstructionsSummaryPurposeTo keep the ICCO and the OWCP office informed of the injured or ill employee sability to return to either limited or full By1. SIDE For initial disability: direct For continuing full or partial disability: ICCO2. SIDE B: Treating PhysicianWhen to Prepare1. After initial injury to accompany the For continuing total disability for each medical visit; or at a minimum of eachtwo For continuing limited duty or follow up examinations when employee hasreturned to Procedures1. The appropriate official completes Side A2. The employee delivers this form, along with the CA-16, job descriptions, andOWCP Form 1500 as appropriate, to the treating The treating physician will complete Side B of the form and either give it,along with the approved job descriptions, to the employee for immediatereturn to the ICCO or, if necessary, mail to the ICCO in the and DistributionFiling and distribution procedures are as follows:1.
2 ICCO will forward the original of the form to OWCP (Note: the forminstructions state to send a copy to OWCP, however the USPS policy is tosend the original CA-17 to OWCP)2. Keep a copy in the Injury Compensation EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS448 OWCP Form CA-17 Instructions (continued)InstructionsSide A is to be completed by the immediate supervisor/control Claimant s complete name; last name, first name, and middle name.(Enter NMN if no middle name)2. Date of injury; Item 10 or 21 on the CA-1 or Item 29 on the SSN consists of NINE Occupation (employee s title).5. Brief description of injury or illness and part(s) of body affected. Refer to Item13 and 14 on the CA-1 or Item 14 on the Work schedule7. Complete as accurately as possible based on the work the employee actuallyperforms in his or her regular : The attending physician completes Side B.
3 A physician s assistant,nurse practitioner, nurse, or other person not within the FECA definition of aphysician is not acceptable as the certifying physician. Certification by aphysician s assistant will be acceptable if such certification is countersignedby a EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS449 OWCP Form CA-17 HBK EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS450 OWCP Form CA-17 (continued)
