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Official Forms For Federal Workers’ Compensation Programs

The OWCP administers four major disability compensation programs that provide wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to certain workers or their dependents who experience work-related injury or occupational disease. These programs:

Since the 1980s, the Office of Workers’ Compensation Programs has developed into an organization that is able to adjust its procedures and resources to address problems as they arise. Each OWCP program has a strategic plan that projects where it should be in the future to achieve its mission, and sets realistic, measurable steps for getting there. Each has as its foundation the belief that government must ensure that injured workers are fairly compensated for their injuries, and that workers’ compensation programs need not be overly bureaucratic or costly.

 

Here is a link to the key forms for FWCP

CA-1 – Notice of Traumatic Injury

  • Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. Use for traumatic injury – employee was hurt because of a single event or within one workday,

CA-2 – Notice of Occupational Disease

  • You have up to 3 years to file your CA-2 from the date of injury. However, we cannot stress the importance of filing your claim sooner than later. Filing your CA-2 protects your job!
  • Your CA-2 must be filed after your initial evaluation with a credentialed DOL doctor.
  •  Keep copies of all documents signed or submitted to the Department of Labor (DOL) by your agency. Specifically, your CA-2 which has a “Receipt” page your supervisor must sign acknowledging that an official injury report was filed with DOL/OWCP.

CA-2a – Notice of Recurrence

  • CA-2a form is a claim for recurrence. If for instance an employee has an injured back and they go out of work for awhile and they’re returned back to work, and then they have a worsening of that back injury condition, they would claim a recurrence.

CA-7 – Claim for Compensation

  • If the employee is receiving continuation of pay and will continue to be disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day period. The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made.

CA-7a – Time Analysis Form

  • This form is used when claiming FECA compensation, including repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.

CA-7b – Leave Buy Back

  • Your supervisor is required to process your claim for compensation within five (5) workdays to the Department of Labor (DOL) through ARC. In addition to submitting the CA7 documentation, it is necessary to submit supporting medical documentation that substantiates that disability exists for the timeframe claimed

CA10 – What a Federal Employee Should Do When Injured at Work

  • If disabled and claiming COP, submit to your employing agency within 10 work days medical evidence that you sustained a disabling traumatic injury. If disabled beyond the COP period, or if you are not entitled to COP, you may claim compensation on form CA-10 or use leave.

CA16 – Authorization for Examination and/or Treatment

  • Form CA-16 – Authorization for Examination and/or Treatment. This form guarantees payment to the care provider if the employee requires medical treatment because of a work-related traumatic injury. Your supervisor should complete page 1 of Form CA-16 and provide it to you for your attending physicians information

CA17 – Duty Status Report

  • Form CA-17Duty Status Report, is a request for a duty status report for an employee when a workers’ compensation claim is filed. This form is a one-page document issued by the U.S. Department of Labor Office of Workers’ Compensation Programs.
  • Injured postal workers are required to fill in form CA17, which is a form which outlines information from a doctor forbidding an injured federal employee from carrying out certain activities due to their inherently physically taxing nature.

CA20 – Attending Physicians Report

  •  Form CA-20 – Attending Physician’s Report. Because it is harder to prove that occupational diseases or injuries that are not recent were caused at work, a form that guarantees payment for something that may not be the government’s responsibility would not be appropriate.  If your claim is accepted, the medical bill will be paid even though a CA-16 was not issued.

OWCP 5c – Work Capacity Evaluation

  • Form OWCP-5C – Work Capacity Evaluation for Musculoskeletal Conditions Form Injured workers need this form for their attending physicians who use this form to report on a federal employee’s work capacity limitations due to musculoskeletal conditions he/she has reported. This workers’ compensation form is authorized by the Federal Workers’ Compensation Act. The Center Annapolis in Maryland created this page for injured federal employees on workers compensation to access the links we have provided. Form OWCP-5c can be downloaded using the links on this website.

OWCP 915 – Claim for Medical Reimbursement

  • This form is used to claim reimbursement for out-of-pocket medical expenses pertaining to the treatment of an accepted condition covered by the Federal Employees’ Compensation Act, the Black Lung Benefits Act, and the Energy Employees Occupational Illness Compensation Program Act of 2000.  Use this form to request reimbursement for medical expenses, transportation costs, loss of wages, and incidental expenses.  If the employee has paid bills for medical, surgical or dental services, supplies or appliances due to an injury sustained in the performance of duty and seeks reimbursement for those expenses, he or she may submit a request for reimbursement on Form OWCP-915, together with an itemized bill on Form OWCP-1500, CMS-1500, OWCP-04 or UB-04 prepared by the provider and a medical report to OWCP.  If the employee does not quality for continuation of pay (for 45 days), this form should be completed and filed with the OWCP as soon as pay stops.  The form should also be submitted when the employee reaches maximum improvement and claims a schedule award.  If the employee is receiving continuation of pay and will continue to be disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day period.  The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made.

OWCP 957 – Medical Travel Refund Request

  • The OWCP-957 form is used to submit all travel expenses. Up to 3 trips can be expensed on one form.
  • Traveling to doctors’ appointments, testing appointments, and picking up medication can get expensive quickly. Luckily, EEOICPA “white card” holders can get reimbursed for any mileage related to medical travel by filling out an OWCP 957 Form.

CA-1122 Short Form 3rd Party Recovery

  • Use form CA-1122 to help get funds back

CA-1108 Long Form 3rd Party Recovery

FECA sf1199a Direct Deposit Form