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Get DoL CA 7a 1996

Block 4 Indicate beginning and ending dates covered by this form. These must be the same as on Forms CA-7 and CA-7b. Agency Statement/Certification I certify the above is accurate except as follows Signature of Agency Official Form CA 7a June 1996 Instructions for Completing Form CA-7A General This form is used when claiming FECA compensation including repurchase of paid leave. Time Analysis Form Reset U*S* Department of Labor Print Office of Workers Compensation Programs Employee Statement - Please carefully read instructions on reverse before filling out this form* 1. Name of Employee Last First Middle 3. OWCP File Number 2. SSN 5. Total Hours Claimed 4. Period Covered by This Form for LWOP for Leave BuyBack To From 6. In Type of Leave Used column use codes S Sick A Annual O Other. If Compensation is claimed for date indicate Yes in Compensation Claimed column* Date s Compensation Claimed Type of Leave Hol Leave Used Number of Hours LWOP Worked Reason for Leave Use/Remarks e*g* doctor visit therapy etc* Totals Signature of Claimant Date Signed 7. It must be used when claiming compensation for more than one consecutive period of leave. Blocks 1 2 and 3 Self-explanatory. Block 5 If claiming compensation for any dates detailed in block 4 state total number of hours claimed for leave without pay and total number of hours of leave. This should be at least 10 hours unless this is your final claim* Block 6 1st Column Show full date. 2nd Column For each date noted in column 1 state Y if you are claiming compensation for that date and N if you are not. 3rd 4th 5th and 6th Columns Show the number of hours of LWOP number of hours worked paid holiday hours and number of hours of paid leave. 7th Column Using the legend provided indicate the type of leave used* State the reason you were off work. For each date for which compensation is claimed there must be medical evidence supporting entitlement. Sign and Date Form and Submit to the Appropriate Agency Official* Block 7 Verify accuracy of hours and status for each date listed* If challenging entitlement for any date attempt to resolve discrepancies prior to submitting claim to OWCP. If discrepancy cannot be resolved indicate the specific basis for the challenge in the space provided*. Time Analysis Form Reset U*S* Department of Labor Print Office of Workers Compensation Programs Employee Statement - Please carefully read instructions on reverse before filling out this form* 1. Name of Employee Last First Middle 3. OWCP File Number 2. SSN 5. Total Hours Claimed 4. Period Covered by This Form for LWOP for Leave BuyBack To From 6. Name of Employee Last First Middle 3. OWCP File Number 2. SSN 5. Total Hours Claimed 4. Period Covered by This Form for LWOP for Leave BuyBack To From 6. In Type of Leave Used column use codes S Sick A Annual O Other. If Compensation is claimed for date indicate Yes in Compensation Claimed column* Date s Compensation Claimed Type of Leave Hol Leave Used Number of Hours LWOP Worked Reason for Leave Use/Remarks e*g* doctor visit therapy etc* Totals Signature of Claimant Date Signed 7. .

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