OOPSPC10 ;HIRMFO/YH-FEDERAL EMPLOYEE'S NOTICE OF TRAUMATIC INJURY - EMPLOYEE ;2/19/98
;;2.0;ASISTS;;Jun 03, 2002
EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
W !,"SD1,277,2,1,4,12,5,0,6,0,7,16901;PU1,28.6;LBFederal Employee's Notice of#;PU1,28.2;LBTraumatic Injury and Claim for#;"
W !,"PU1,27.8;LBContinuation of Pay/Compensation#;"
W !,"SD1,277,2,1,4,12,5,0,6,1,7,23;PU11,28.5;LBU.S. Department of Labor#;"
W !,"SD1,277,2,1,4,10,5,0,6,0,7,16901;PU11,28.1;LBEmployment Standards Administration#;"
W !,"PU11,27.8;LBOffice of Workers' Compensation Programs#;"
W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,27.3;LBEmployee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.#"
W !,"PU1,26.9;LBWitness: Complete bottom section 16.#;"
W !,"PU1,26.5;LBEmploying Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.#;"
W !,"PU.9,26;FT10,10;RA21,26.4;EA21,26.4;PU1,26.1;LBEmployee Data#;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,25.7;LB1. Name of employee (Last, First, Middle)#;"
W !,"PU16.5,25.7;LB2. Social Security Number#;PU1,25.2;PD21,25.2;PU16.4,26;PD16.4,25.2;"
W !,"PU1,24.9;LB3. Date of birth#;PU3.4,24.9;LBMo.#;PU4.3,24.9;LBDay#;PU5.3,24.9;LBYr.#;"
W !,"PU6.8,24.4;PD6.8,25.2;PU6.9,24.9;LB4. Sex#;PU10.2,25.2;PD10.2,24.4;PU10.3,24.9;LB5. Home telephone#;"
W !,"PU15,25.2;PD15,24.4;PU15.1,24.9;LB6. Grade as of#;"
W !,"PU15.5,24.6;LBdate of injury#;"
W !,"PU1,24.1;LB7. Employee's home mailing address (Include city, state, and ZIP code)#;PU1,23.4;PD16.4,23.4;"
W !,"PU16.5,24.1;LB8. Dependents#;PU16.9,23.6;EA17.1,23.8;PU17.3,23.6;LBWife, Husband#;"
W !,"PU16.9,23.2;EA17.1,23.4;PU17.3,23.2;LBChildren under 18 years#;"
W !,"PU.9,22;RA21,22.4;EA21,22.4;PU1,22.1;SD1,277,2,1,4,9,5,0,6,1,7,23;LBDescription of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU1,21.7;LB9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)#;"
W !,"PU1,20.8;PD21,20.8;PU1,20.5;LB10. Date injury occurred#;PU4.6,19.6;PD4.6,20.8;PU7.7,19.6,PD7.7,20.8;PU11.2,19.6;PD11.2,20.8;"
W !,"PU4.7,20.5;LBTime#;PU7.8,20.5;LB11. Date of this notice#;PU11.3,20.5;LB12. Employee's occupation#;"
W !,"PU16.4,18.3;LBa. Occupation code#;PU16.4,17.3;LBb. Type code#;PU18.4,17.6;PD18.4,16.6;PU18.5,17.3;LBc. Source code#;"
W !,"PU16.4,16.3;LBOWCP Use - NOI Code#;"
W !,"PU1,19.3;LB13. Cause of injury (Describe what happened and why)#;"
W !,"PU1,17.3;LB14. Nature of injury (Identify both the injury and the part of body, e.g., fracture of left leg)#;"
W !,"PU.9,15.2;RA21,15.6;EA21,15.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,15.3;LBEmployee Signature#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU1,14.9;LB15. I certify, under penalty of law, that the injury described above#;"
W !,"LB was sustained in performance of duty as an employee of the#;"
W !,"PU1.5,14.6;LBUnited States Government and that it was not caused by my willful misconduct#;"
W !,"LB, intent to injure myself or another person, nor by#;"
W !,"PU1.5,14.3;LBmy intoxication. I hereby claim medical treatment, if needed, and the following,#;"
W !,"LB as checked below, while disabled for work:#;"
W !,"PU1.5,13.5;EA1.7,13.7;PU1.9,13.5;LBa. Continuation of regular pay (COP) not to exceed 45#;"
W !,"LB days and compensation for wage loss if disability for work continues#;"
W !,"PU2.3,13.2;LBbeyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick#;"
W !,"PU2.3,12.9;LBor annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.#;"
W !,"PU1.5,12.4;EA1.7,12.6;PU1.9,12.4;LBb. Sick and/or Annual Leave#;"
W !,"PU1.7,11.9;LBI hereby authorize any physician or hospital (or any other person, institution,#;"
W !,"LB corporation, or government agency) to furnish any#;"
W !,"PU1.7,11.6;LBdesired information to the U.S. Department of Labor, Office of Workers' Compensation#;"
W !,"LB Programs (or to its official representative).#;"
W !,"PU1.7,11.3;LBThis authorization also permits any official representative of the Office#;"
W !,"LB to examine and to copy any records concerning me.#;"
W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,10.6;LBSignature of employee or person acting on his/her behalf#;PU9.3,10.6;PD21,10.6;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU1,10.1;LBAny person who knowingly makes any false statement,#;"
W !,"LB misrepresentation, concealment of fact or any other act of fraud to obtain compensation#;"
W !,"PU1,9.8;LBas provided by the FECA or who knowingly accepts compensation to which that person is not#;"
W !,"LB entitled is subject to civil or administrative#;"
W !,"PU1,9.5;LBremedies as well as felony criminal prosecution and may, under appropriate criminal provisions,#;"
W !,"LB be punished by a fine or imprisonment or both.#;"
W !,"SD1,277,2,1,4,9,5,0,6,1,7,23;PU1,8.9;LBHave your supervisor complete the receipt attached to this form#;"
W !,"LB and return it to you for your records.#;"
W !,"PU.9,8.2;RA21,8.6;EA21,8.6;PU1,8.3;LBWitness Statement#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU1,7.9;LB16. Statement of witness (Describe what you saw, heard, or know about this injury)#;"
W !,"PU1,4.6;PD21,4.6;PU1,4.3;LBName of witness#;"
W !,"PU8.9,4.3;LBSignature of witness#;PU17.6,4.3;LBDate signed#;"
W !,"PU1,3.8;PD21,3.8;PU1,3.5;LBAddress#;PU8.9,3.5;LBCity#;PU13.6,3.5;LBState#;PU17.6,3.5;LBZIP Code#;"
W !,"PU1,3;PD21,3;PU17.5,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBForm CA-1#;PU17.5,2.1;LBRev. Apr. 1999#;"
;CALL TO EXTRACT DATA
W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q