Federal Employee's Notice of Traumatic Injury and …

1 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).

2 Thisauthorizatio gnatureofemplo ye eo rpersonactingonhis/herbehalf DateAnypersonwhoknowinglymakesanyfalsest atement,misrepresentation,concealmentoff actoranyotheractoffraudtoobtaincompensat ionasprovidedbytheFECA orwhoknowingl yacceptscompensationtowhichthatpersonisn otentitledissubjecttocivi loradministrativeremediesaswellasfelonyc riminalprosecutionandmay,underappropriat ecriminalprovisions, tatementofwitness(Describewhatyousaw,hea rd,orknowaboutthisinj ury)Nameofwitness Signatureofwitness Dat esignedAddress City State ,HusbandChildrenunder18yearsOtherCity State ZIPCode OfficialSu pervisor'sReport:Pleasecompleteinformati o nrequestedbelow:Supervisor' ce(includestreet address, city ,sta te,andZIP code)OWCPA gencyCodeOSHASi 'sdut ystation(include street address, city, state, and ZIP code) City : Sun.

3 Mon. Tues. Wed. Thurs. Fri. yemployee'swillfulmisconduct,in toxi cation,orinte ntt oinjureselforanother? Yes(If"Yes,"explain) Mo. Day Mo. Day Mo. Day Mo. Day Mo. Day Mo. Day Tim Yes No(I f"No,"explain) nju ryagreewithstatementsoftheemployeeand/or witnesses? Yes No (If"No,"explain) No(If"No,"gotoitem32.) tdate Mo. Day (includestreet address, city,state,andZIPcode) rs tprovidingmedica lcare(includestreet address, city,s tate,ZIPcode) fpay,stat ethereasonindetail. stopped work $PerSi gnat ureofSuperv isorandFilingInstruct oanyfalsestatement,misrepresentation,con cealmentoffact,etc .,i nrespectofthi sclaimmayalsobesubjecttoappropriat :Nameofsupervisor(Typeorprint)Signatureo fsupervisorSupervisor' sTitle Offi Nolosttimeandnomedicalexpense:Placethi sforminem ployee'smedicalfolder(SF-66-D)Nolosttime ,medicalexpenseincurredorexpected:forwar dthisformtoOWCPL osttimecoveredbyleave,LWOP,orCOP.

4 ForwardthisformtoOWCPFirs tA idInjury 'sretirementcoverageFER SCSRS Other,(identify)City State ZIPCodeCity State ZIPCodeCity State ZIPCode State ZIPCode Instructionsfo rCompletingFormCA-1 Completealli tem sonyoursectiono ftheform .I fadditionalspaceisrequiredtoexplainorcla rifyanypoint, sontheformwhichmayrequirefurtherclarifi (Orpersonactingontheemployees'behalf)15) ElectionofCOP/Leave13)CauseofinjuryDescr ibei ( :i fyoufell,howfardidyoufal landinIfyouaredisabledforworkasaresultof thisinjuryandfiledCA-1withinthi rt ydaysoftheinjury,youmayb eentitle dtoreceivecontinuationofpay(COP ) , )14)NatureofInjuryGiveacompletedescripti onofthecondition(s) e( ,fracturedleftleg:cutonrightindexfinger) .

5 Supervisor33)Firstdatemedicalcarereceive dAtth etim etheformisreceived, s17through39,thesupervisorisresponsiblef orobtainingthewitnessstatementi nItem16andforfillinginthepropercodesThed ateofthefirstvisi tt oth ep hysicianlistedi nite )Iftheemployingagencycontrovertscontinua tionofpay, ,b, fmedicalexpenseorlosttimei sincurredo rexpected,thecompletedformshouldb esenttoOWCP within10workingdaysafteri ti (disputed)foranyreason;however,theemploy ingagencymayrefusetopayCOPonlyi fthecontroversionisbasedupononeofthenine reasonsgivenbelow:Thesupervisorshouldals ) ,theemployeeshouldbenotifiedandthereason forcontroversionexplainedtohi morTheemployeeisavolunteerworkingwithout payorfornomi nalpay,oramemberoftheofficestaffofaforme rPresident;b) )AgencynameandaddressofreportingofficeTh eemployeeisnotacitizenoraresidentoftheUn itedStatesorCanada;Thenameandaddressofth eofficet owhichcorrespondencefromOWCP shouldbesent(ifapplicable,theaddressofth epersonnelorcompensationoffice).

6 Theinjuryoccurredofftheemployingagency's premisesandtheemployeewasnotinvol vedi nofficial"offpremise"duties;18)Dutystati ons treetaddressandzipcodeTheaddressandzipco deoftheestablishmentwheretheemployeeactu all )Theinjurywasproximatelycausedbytheemplo yee'swillfulmisconduct,intenttobringabou tinjuryordeathtoselforanotherperson,orin toxication;19) einjury;30)Wasinjurycausedbythirdparty?A thirdpartyi sanindividualororganization(otherthanthe injuredemployeeortheFederalgovernment)wh oisliableforth ,thedriverofavehicl ecausinganaccidentinwhicha nemployeeisinjured,theownerofaWorkstoppa gefirstoccurred45daysorm orefollowingtheinjury;Theemployeeinitial l yreportedtheinjuryafterhisorheremploymen twasterminated;orbuildingwhereunsafecond itionscauseanemployeetofall ,andamanufacturerwhosedefectiveproductca usesanemployee'sinjury,couldal )Th eemployeeIsenrolledi ntheCivilAi rPa trol ,PeaceCorps,Yout hConservationCorps,WorkStudyPrograms,oro thersimilargr )Nameanda ddressofphysicianfirstprovidingmedicalca reThenameandaddressofthephysicianwhofirs tprovidedmedi (notaphysician)inth eemployingagency'shealthunitorclinic,ind icatethi xa(OccupationCode),Bo xb(Typ eCode),Boxc(SourceCode),OSHASiteCo deOWCPA gencyCodeThi si safour-digi t(orfourdigitplustwoletter)codeusedbyOWC P toidentifyt , yandHealthAdministrati on(OSHA)requiresallemployingagenciestoco mpletetheseitem ," )c)d)f)h) BenefitsforEmplo yeesundertheFederalEmployees'Compensatio nact(FECA)

7 TheFECA,whi chi sadministeredbytheOfficeofWorkers'Compen sationP rograms(OWCP),providesthefollowingbenefi tsforjob-relatedtraumaticinjuries:(4)Voc ationalrehabilitationandrelatedservi ceswhere(1)Continuationofpayfordisabilit yresultingfromtraumatic,job-relatedinjur y,nottoexceed45calendardays.(Tobeeligibl ef orcontinuationofpay,theemployee,orsomeon eacti ngonhis/herbehalf,mu stfil eFormCA-1withi n30daysfollowingtheinjuryandprovidemedic a levidenceinsupportofdisabilitywi thi n1 'stheemployee'spay,thepaymustnotbeinterr uptedunlessoneoftheprovision' (5) njuredemployeemaychoosethephysicianwhopr ovidesinitia ,25milesf romtheplaceofinjury,placeofemploym ent ,oremployee'shomei sareasonabledistancetot edi ,availablefromthepersonneloffice,shouldb estudiedBEFORE adecisionismadetouseleave.)

8 (2)Paymentofcompensationforwagelossafter theexpirationofCOP,i fdisabilityextendsbeyondsuchpoint, ,FormCA-7,withsupportingmedicalevidence, ,theformshouldbefiledonthe40t ,reviewtheregulationsgoverningtheadminis trationoftheFECA(CodeofFederalRegulation s,Chapter20,Part10)orpamphletCA-810.(3)P aymentofcompensationforpermanentimpairme ntofcertainorgans,members,orfunctionsoft hebody(suchaslossorlossofuseofanarmorkid ney,lossofvision,et c.),orforseriousdefringementofthehead,fa ce, ,asamended( ),youareherebynotifie dthat:(1)TheFederalEmployees'Compensatio nAct,asamendedandextended( ,etseq.)(FECA)i sadministeredbytheOfficeofWorkers'Compen sationProgramsoft ,whichreceivesandmaintainspersonalinform ationonclaimantsandtheirimmediat ef amilies.(2)InformationwhichtheOfficehasw illbeusedtodetermineeligibilityforandthe amountofbenefitspayableundertheFECA,andm aybeverifiedthroughcomputermatchesorothe rappropriatemeans.

9 (3)Informati onmaybegiventotheFederalagencywhichemplo yedtheclaimantatthetim eofinjuryinordertoverifystatementsmade,a nswerquestionsconcerningthestatu softheclaim ,verifybilling,andtoconsiderissuesrelati ngtoretention,rehire,orotherrelevantmatt ers.(4)InformationmayalsobegiventootherF ederalagencies,othergovernmententities,a ndtoprivate-sectoragenciesand/oremployer saspartofrehabilitativeandotherreturn-to -workprogramsa ndservices.(5)Informationmaybedisclosedt ophysiciansandotherhealthcareprovidersfo ruseinprovidingtreatm entormedical/vocationalrehabilitation,ma kingevaluationsfortheOffice,andforotherp urposesrelatedtothemedicalmanagementofth eclaim.(6)Informationmaybegivent oFederal,stat eandlocalagenciesforlawenforcementpurpos es,toobtaininformationrelevantt oadecisionundertheFECA,todeterminewhethe rbenefitsarebeingpaidproperly,includingw hetherprohibiteddualpaymentsarebeingmade ,and,whereappropriate,topursuesalary/adm inis trati veoffsetanddebtcollectio nactionsrequiredorpermittedbytheFECAand/ ortheDebtCollectionAct.

10 (7)Disclosureoftheclaimant'ssocialsecuri tynumber(SSN)ortaxidentifyingnumber(TIN) onthisformism ) ,andotherinformationmaintainedbytheOffic e,maybeusedforidentification,tosupportde btcollectioneffort scarriedonbytheFederalgovernment,andforo therpurposesrequiredorauthorizedbylaw.(8 )Failuret odiscloseallrequestedinformationmaydelay theprocessingNote:Thisn otic ea ppliestoallformsrequestinginformationtha tyoumightreceivefromtheOfficei eofInjurysustainedby* :1999-454-845/12704ofth eclai morthepaymentofbenefits,ormayresulti (Nameofinjuredemployee)Whichoccurredon(M o.,Day,Yr.)At(Location)SignatureofOffici alSuperior TitleDate(Mo.,Day,Yr.)