Duty Status Report Reset Print U.S. Department of Labor Office of Workers ' Compensation Programs This form is provided for the purpose of obtaining a duty status report for the employee named below.
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How to fill out the Ca-17.pdf online
The Ca-17 form, also known as the Duty Status Report, is essential for documenting an employee's work capabilities following an injury. This guide provides clear, step-by-step instructions on filling out the form online to ensure accuracy and compliance with requirements.
Follow the steps to complete the Ca-17 form online.
- Click the ‘Get Form’ button to access the Ca-17 form and open it for editing.
- Begin filling out Side A of the form, starting with the employee's name (last, first, middle) and the date of injury. If known, include the OWCP file number in the designated area.
- Provide the employee's social security number and occupation in the respective fields on Side A.
- Describe how the injury occurred and specify the parts of the body affected in the provided section on Side A.
- Indicate the hours the employee typically works per day and days per week in the designated areas.
- Specify the usual work requirements and check whether the employee performs these tasks continuously or intermittently. Include the number of hours and maximum weight lifted per day.
- Proceed to Side B of the form for the physician to complete. They will assess whether the history of injury given corresponds with the employee's account, describe clinical findings, and provide a diagnosis.
- The physician should sign and date the form, ensuring all relevant sections regarding the employee's ability to return to work are addressed.
- Once all sections are complete, save any changes made to the form. Users can then download, print, or share the completed Ca-17 form as necessary.
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Get answers to your most pressing questions about US Legal Forms API.
What is a ca7a form?
Instructions for Completing Form CA-7A Time Analysis. General: 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.
What are the types of injuries on duty?
The types of injuries of duties (IOD) range from minor contusions to amputations of digits. Other injuries include removal of foreign bodies in the eyes and in the skin as a result of, for example, grinding metal. Burns, abrasions and lacerations are all in a days work.
Can my employer cancel my health insurance while on workers comp California?
The employer is required to maintain the same level of health insurance benefits the worker had while he was employed. If the worker has to be off of work longer than the allotted 12 weeks, the employer may cancel the health insurance benefits.
What is a form CA-17?
It is recommended that you take with you a form CA-17 - Duty Status Report to give to the attending physician. This form provides your supervisor and OWCP with interim medical reports containing information as to your ability to return to any type of work.
How long does Owcp have to process a CA 7?
Employing agency (EA) should submit completed Form CA-7 to the Office of Workers' Compensation Programs (OWCP) within five work days of receipt from IW. OWCP tries to review wage loss claims within five days of receipt, and take action to develop or pay within 14 days of receipt from EA.
What is a CA-17 form used for?
CA-17 - Duty Status Report. This form allows the physician to keep your supervisor updated on your work restrictions and/or duty status.
Who fills out CA-17?
There are two sides to the CA-17: Side A is completed by the employee's supervisor and Side B is completed by the employee's physician. A properly completed CA-17 should give the doctor an accurate picture of a worker's daily work duties so that accurate work restrictions can be noted.
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