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fillable_CA1.doc - Federal Employee's Notice of Traumatic...

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Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Employee: Please complete all boxes 1 - 15 below. Do not complete shaded areas. Witness: Complete bottom section 16. Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c. 1. Name of employee (Last, First, Middle) 2. Social Security Number 3. Date of Birth (Mo. Day Yr.) 4. Sex Male Female 5. Home Telephone (include area code) 6. Grade as of date of injury Level Step 7. Employee's home mailing address (Include city, state, and zip code) 8. Dependents Wife, Husband Children under 18 years Other Description of Injury 9. Place where injury occurred (e.g., 2 nd floor, Main Post Office Bldg., 12 th & Pine) 10. Date Injury Occurred (Mo. Day, Yr.) Time a.m. p.m. 11. Date of this notice (Mo., Day, Yr.) 12. Employee's Occupation 13. Cause of Injury (Describe what happened and why.) 14. Nature of Injury (Identify both the injury and the part of body, e.g., fracture of left leg) a. Occupation code b. Type code c. Source code OWCP Use--NOI Code Employee Signature 15. I certify, under penalty of law, that the injury described above was sustained in performance of duty as an employee of the United States Government and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication. I hereby claim medical treatment, if needed, and the following as checked below, while disabled for work: a. Continuation of regular pay (COP) not to exceed 45 days and compensation for wage loss if disability for work continues beyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick or annual leave, or be deemed an overpayment within the meaning of 5 USC 5584. b. Sick and/or Annual Leave I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative). This authorization also permits any official representative of the Office to examine and to copy any records concerning me. Signature of employee or person acting on his/her behalf . Date Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Have your supervisor complete the receipt attached to this form and return it to you for your records.
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