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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 1, Chapter 8: Manual Exhibit 1-8-A

"Injury Compensation Forms Description"

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 following 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 on employee's behalf; witness (if any); supervisor. By employee within 30 days (but will meet statutory time requirements if filed no later than 3 years after the injury); by supervisor within 10 working days following receipt of the form from the employee. Supervisor, by employee or someone acting on employee's behalf, then to the appropriate OWCP office by the 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 medical charge against the compensation fund; (2) the employee loses time from work on any day because of the disease, whether the time is charged to leave or the employee chooses to claim 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 3 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 the appropriate OWCP office by the supervisor.
CA-2a Notice of Employee's Recurrence of Disabilty 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 or someone acting on employee's behalf; witness (if any); supervisor. Immediately upon receiving notice that the employee has suffered a recurrence.  When the employee stops work as a result of recurring disability, the employee shall advise the supervisor whether he/she wishes to continue to receive regular pay provided qualifications are met or charge the absence to sick or annual leave. 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 the 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 not later than 3 years after death.  If the death resulted from an injury for which a disability claim was timely filed, the time requirements for filing death claim have been met.

Supervisor, by claimant or by 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 3 years after death.  If the death resulted from an injury for which a disability claim was timely filed, the time requirements for filing 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 employment - related death of an employee. Supervisor. Within 10 workdays after knowledge by supervisor of the employment-related death of an employee.

Appropriate OWCP office.
CA-7 Claims 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 case of traumatic injury, the form must be completed and filed with OWCP not more than 5 working days before the termination of the 45 days.  In case of occupational disease, this form should be submitted as soon as pay stops.

Supervisor, by employee or someone acting on employee's behalf; then to the appropriate OWCP office by the supervisor.
CA-8 Claim for Continuing Compensation on Account of Disability. Claims compensation when loss of pay continues beyond the time covered by the claim on Form CA-7. Employee or someone acting on employee's behalf; supervisor, and attending physician (on attached Form CA-20a).

At least 5 days before the end of the period claimed on Form CA-7 or CA-8 for the period of disability supported by medical evidence Supervisor, by employee or someone acting on employee's behalf; then to the appropriate OWCP office by the supervisor.
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 pychologist, 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/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 followed first examination and/or treatment.


Part B - By attending physician or medical facility as promptly as possible after initial examination.
Part A - Physician or medical facility.




Part B - 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 the employing agency and copy to appropriate OWCP office.

CA-20 Attending Physicians 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 Attending Physician's Supplemental Report Provides OWCP with additional medical information in connection with supplemental claim filed on attached Form CA-8. Attending Physician. Promptly upon completion of examination or most recent treatment.

Appropriate OWCP office.
OWCP
1500a
Federal Employee's Compensation Program 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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