From OWCP CA-810 Appendix A. Basic Forms from FedupFeds
| Form No. | Form Title | Purpose | Prepared By | When Submitted | Completed Forms Sent to |
| CA-1 | Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation | Notifies supervisor of a traumatic injury and serves as the report to OWCP when (1) the employee has sustained a traumatic injury which is likely to result in a medical charge against the compensation fund; (2) the employee loses time from work on any day after the injury date, whether the time is charged to leave or to continuation of pay; (3) disability for work may subsequently occur; (4) permanent impairment appears likely; or (5) serious disfigurement of the face, head, or neck is likely to result | Employee or someone acting in employee's behalf; witness (if any); supervisor | By employee within 30 days (but will meet statutory time requirements if filed no later than three years after the injury); by supervisor within 10 work days following receipt of the form from the employee | Supervisor, by employee or someone acting on employee's behalf; then to appropriate OWCP office by supervisor |
| CA-2 | Federal Employee's Notice of Occupational Disease and Claim for Compensation | Notifies supervisor of an occupational disease and serves as the report to OWCP when (1) the disease is likely to result in a medical charge against the compensation fund; (2) the employee loses time from work because of the disease, whether the time is charged to leave or the employee claims injury compensation; (3) disability for work may subsequently occur; (4) permanent impairment appears likely; or (5) serious disfigurement of the face, head, or neck is likely to result | Employee or someone acting on employee's behalf; witness (if any); supervisor | By employee within 30 days (but will meet statutory time requirements if filed no later than three years after the injury); by supervisor within 10 work days after receipt of the form from the employee | Supervisor, by employee or someone acting on employee's behalf; then to appropriate OWCP office by supervisor |
| CA-2a | Notice of Employee's Recurrence of Disability and Claim for Pay/ Compensation | Notifies OWCP that an employee, after returning to work, is again disabled due to a prior injury or occupational disease. It also serves as a claim for continuation of pay or for compensation based on the recurrence of a previously reported disability | Employee | Immediately upon receiving notice that the employee has suffered a recurrence. An employee who stops work as a result of recurring disability shall advise the supervisor whether he or she wishes to continue receiving regular pay (if eligible) or charge the absence to sick or annual leave | Supervisor, by employee or someone acting on employee's behalf, then to appropriate OWCP office. An employee no longer employed by the Federal government should complete Parts A and C and submit all materials directly to appropriate OWCP office |
| CA-3 | Report of Termination of Disability and/or Payment | Notifies OWCP that disability from injury has terminated and/or that continuation of pay has terminated and/or that employee has returned to work | Supervisor | Immediately after disability or continuation of pay terminates, or the employee returns to work | Appropriate OWCP office |
| CA-5 | Claim for Compensation by Widow, Widower and/or Children | Claims compensation on behalf of these dependents when injury results in death | Person claiming compensation (for self or on behalf of children) and attending physician | Within 30 days, if possible, but no later than three years after death. If the death resulted from an injury for which a disability claim was timely filed, the time requirements for filing the death claim have been met | Supervisor, by claimant or someone acting on claimant's behalf; then to appropriate OWCP office |
| CA-5b | Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren | Claims compensation for these dependents when injury results in death | Person claiming compensation (or guardian on behalf of children) and attending physician | Within 30 days, if possible, but not later than three years after death. If the death resulted from an injury for which a disability claim was timely filed, the time requirements for filing the death claim have been met | Supervisor, by claimant or someone acting on claimant's behalf; then to appropriate OWCP office |
| CA-6 | Official Superior's Report of Employee's Death | Notifies OWCP of the work-related death of an employee | Supervisor | Within 10 work days after knowledge by supervisor of an employee's work-related death | Appropriate OWCP office |
| CA-7 | Claim for Compensation on Account of Traumatic Injury or Occupational Disease | Claims compensation if (1) medical evidence shows disability is expected (and is not covered by COP in traumatic cases); (2) the injury has resulted in permanent impairment involving the total or partial loss, or loss of use, of certain parts of the body or serious disfigurement of the face, head or neck; (3) loss of wage-earning capacity has resulted | Employee or someone acting on employee's behalf; supervisor, and attending physician (on attached Form CA-20) | In traumatic injury cases, the form must be completed and filed with OWCP not more than five work days before the termination of the 45 days of COP, or within 10 days following termination of pay. In occupational disease cases, the form should be submitted as soon as pay stops | Supervisor, by employee or someone acting on employee's behalf; then to appropriate OWCP office by the supervisor |
| CA-8 no longer in use as of 1-4-99 use CA-7 instead | |||||
| CA-16 | Authorization for Examination and/or Treatment | Authorizes an injured employee to obtain examination and/or treatment for up to 60 days and provides OWCP with initial medical report. Treatment may be obtained from a local hospital or physician (who may be a surgeon, osteopath, podiatrist, dentist, clinical psychologist, optometrist, or, under certain circumstances, a chiropractor), or from a U. S. medical facility, if available. May also be used for illness or disease if prior approval is obtained from OWCP. The employee may initially select the medical provider of his or her choice but must request any change from OWCP | Part A--Supervisor Part B--Attending Physician | Part
A--By supervisor, in duplicate, within 48 hours following first examination and/or
treatment Part B--By attending physician or medical facility as promptly as possible after initial examination |
Part A--to Physician or medical facility Part B--to Appropriate OWCP office |
| CA-17 | Duty Status Report | In traumatic injury cases, provides supervisor and OWCP with interim medical report containing information as to employee's ability to return to any type of work | Supervisor and attending physician | Promptly upon completion of examination or most recent treatment | Original to employing agency, which should send copy to appropriate OWCP office |
| CA-20 | Attending Physician's Report | Provides medical support for claim and is attached to Form CA-7; provides OWCP with medical information | Attending physician | Promptly upon completion of examination or most recent treatment | Appropriate OWCP office |
| CA-20a no longer in use as of 1-4-99 use CA-20 instead | |||||
| OWCP 1500 |
Medical Provider's Claim Form | Provides OWCP with standard billing form to facilitate payment of medical bills. The form should accompany the CA-16 when employee is referred to a physician | Attending physician; employee must sign in item 12 | Promptly upon completion of examination or treatment; physician may submit in usual billing cycle | Appropriate OWCP office. |
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