OOPSPC70 ;HIRMFO/YH-Instructions for Completing Form CA-1 (PART 1) ;5/7/98
;;2.0;ASISTS;;Jun 03, 2002
EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
W !,$CHAR(27),"E",$CHAR(27),"&l1E",$CHAR(27),"*c5952x7920Y",$CHAR(27),"%0B",$CHAR(27),"&s1#C"
W !,"IN;SP1;IP;PW.3;SC0,22,0,29,1;"
W !,"DT#,1;SD1,277,2,1,4,10,5,0,6,2,7,23;PU.5,28.3;LBInstructions for Completing Form CA-1#;PU.5,28.1;PD21,28.1;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.6;LBComplete all items on your section of the form. If additional space is required to #;"
W !,"LBexplain or clarify any point, attach a supplemental#;"
W !,"PU.5,27.3;LBstatement to the form. Some of the items on the form which may require #;"
W !,"LBfurther clarification are explained below.#"
W !,"FT10,10;PU.5,26.5;RA21,27;EA21,27;PU.6,26.6;LBEmployee (Or person acting on the employees' behalf)#;"
W !,"PU.5,26.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB13) Cause of Injury#;"
W !,"PU11,26.1;LB15) Election of COP/Leave#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,25.7;LBDescribe in detail how and why the injury occurred. Give#;"
W !,"PU11,25.7;LBIf you are disabled for work as a result of this injury and filed#;"
W !,"PU11,25.4;LBCA-1 within thirty days of the injury, you may be entitled to receive#;"
W !,"PU.5,25.4;LBappropriate details (e.g.: if you fell, how far did you fall and in#;"
W !,"PU11,25.1;LBcontinuation of pay (COP) from your employing agency. COP is#;"
W !,"PU11,24.8;LBpaid for up to 45 calendar days of disability, and is not charged#;"
W !,"PU11,24.5;LBagainst sick or annual leave. If you elect sick or annual leave#;"
W !,"PU11,24.2;LByou may not claim compensation to repurchase leave used#;"
W !,"PU11,23.9;LBduring the 45 days of COP entitlement.#;"
W !,"PU.5,25.1;LBwhat position did you land?)#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,24.5;LB14) Nature of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,24.1;LBGive a complete description of the condition(s) resulting from#;"
W !,"PU.5,23.8;LByour injury. Specify the right or left side if applicable (e.g.,#;"
W !,"PU.5,23.5;LBfractured left leg: cut on right index finger).#;"
W !,"PU.5,22.6;RA21,23.1;EA21,23.1;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.6,22.7;LBSupervisor#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,22.1;LBAt the time the form is received, complete the receipt of notice of#;"
W !,"PU11,22.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB33) First date medical care received#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,21.8;LBinjury and give it to the employee. In addition to completing#;"
W !,"PU.5,21.5;LBitems 17 through 39, the supervisor is responsible for obtaining#;"
W !,"PU11,21.6;LBThe date of the first visit to the physician listed in item 31.#"
W !,"PU.5,21.2;LBthe witness statement in item 16 and for filling in the proper codes#;"
W !,"PU.5,20.9;LBin shaded boxes a, b, and c on the front of the form. If medical#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20.8;LB36) If the emloying agency controverts continuation#;"
W 1,"PU11.5,20.4;LBof pay, state, the reason in detail#;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,20.6;LBexpense or lost time is incurred or expected, the completed form#;"
W !,"PU.5,20.3;LBshould be sent to OWCP within 10 working days after it is received.#;"
W !,"PU.5,19.5;LBThe supervisor should also submit any other information or#;"
W !,"PU.5,19.2;LBevidence pertinent to the merits of this claim.#;"
W !,"PU11,19.9;LBCOP may be controverted (disputed) for any reason; however,#;"
W !,"PU11,19.6;LBthe employing agency may refuse to pay COP only if the#;"
W !,"PU11,19.3;LBcontroversion is based upon one of the nine reasons given#;"
W !,"PU11,19;LBbelow:#"
D ^OOPSPC71
W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HOOPSPC70 3798 printed Nov 22, 2024@16:49:42 Page 2
OOPSPC70 ;HIRMFO/YH-Instructions for Completing Form CA-1 (PART 1) ;5/7/98
+1 ;;2.0;ASISTS;;Jun 03, 2002
EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
+1 WRITE !,$CHAR(27),"E",$CHAR(27),"&l1E",$CHAR(27),"*c5952x7920Y",$CHAR(27),"%0B",$CHAR(27),"&s1#C"
+2 WRITE !,"IN;SP1;IP;PW.3;SC0,22,0,29,1;"
+3 WRITE !,"DT#,1;SD1,277,2,1,4,10,5,0,6,2,7,23;PU.5,28.3;LBInstructions for Completing Form CA-1#;PU.5,28.1;PD21,28.1;"
+4 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.6;LBComplete all items on your section of the form. If additional space is required to #;"
+5 WRITE !,"LBexplain or clarify any point, attach a supplemental#;"
+6 WRITE !,"PU.5,27.3;LBstatement to the form. Some of the items on the form which may require #;"
+7 WRITE !,"LBfurther clarification are explained below.#"
+8 WRITE !,"FT10,10;PU.5,26.5;RA21,27;EA21,27;PU.6,26.6;LBEmployee (Or person acting on the employees' behalf)#;"
+9 WRITE !,"PU.5,26.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB13) Cause of Injury#;"
+10 WRITE !,"PU11,26.1;LB15) Election of COP/Leave#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+11 WRITE !,"PU.5,25.7;LBDescribe in detail how and why the injury occurred. Give#;"
+12 WRITE !,"PU11,25.7;LBIf you are disabled for work as a result of this injury and filed#;"
+13 WRITE !,"PU11,25.4;LBCA-1 within thirty days of the injury, you may be entitled to receive#;"
+14 WRITE !,"PU.5,25.4;LBappropriate details (e.g.: if you fell, how far did you fall and in#;"
+15 WRITE !,"PU11,25.1;LBcontinuation of pay (COP) from your employing agency. COP is#;"
+16 WRITE !,"PU11,24.8;LBpaid for up to 45 calendar days of disability, and is not charged#;"
+17 WRITE !,"PU11,24.5;LBagainst sick or annual leave. If you elect sick or annual leave#;"
+18 WRITE !,"PU11,24.2;LByou may not claim compensation to repurchase leave used#;"
+19 WRITE !,"PU11,23.9;LBduring the 45 days of COP entitlement.#;"
+20 WRITE !,"PU.5,25.1;LBwhat position did you land?)#;"
+21 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,24.5;LB14) Nature of Injury#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+22 WRITE !,"PU.5,24.1;LBGive a complete description of the condition(s) resulting from#;"
+23 WRITE !,"PU.5,23.8;LByour injury. Specify the right or left side if applicable (e.g.,#;"
+24 WRITE !,"PU.5,23.5;LBfractured left leg: cut on right index finger).#;"
+25 WRITE !,"PU.5,22.6;RA21,23.1;EA21,23.1;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.6,22.7;LBSupervisor#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+26 WRITE !,"PU.5,22.1;LBAt the time the form is received, complete the receipt of notice of#;"
+27 WRITE !,"PU11,22.1;SD1,277,2,1,4,9,5,0,6,2,7,23;LB33) First date medical care received#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+28 WRITE !,"PU.5,21.8;LBinjury and give it to the employee. In addition to completing#;"
+29 WRITE !,"PU.5,21.5;LBitems 17 through 39, the supervisor is responsible for obtaining#;"
+30 WRITE !,"PU11,21.6;LBThe date of the first visit to the physician listed in item 31.#"
+31 WRITE !,"PU.5,21.2;LBthe witness statement in item 16 and for filling in the proper codes#;"
+32 WRITE !,"PU.5,20.9;LBin shaded boxes a, b, and c on the front of the form. If medical#;"
+33 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20.8;LB36) If the emloying agency controverts continuation#;"
+34 WRITE 1,"PU11.5,20.4;LBof pay, state, the reason in detail#;"
+35 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,20.6;LBexpense or lost time is incurred or expected, the completed form#;"
+36 WRITE !,"PU.5,20.3;LBshould be sent to OWCP within 10 working days after it is received.#;"
+37 WRITE !,"PU.5,19.5;LBThe supervisor should also submit any other information or#;"
+38 WRITE !,"PU.5,19.2;LBevidence pertinent to the merits of this claim.#;"
+39 WRITE !,"PU11,19.9;LBCOP may be controverted (disputed) for any reason; however,#;"
+40 WRITE !,"PU11,19.6;LBthe employing agency may refuse to pay COP only if the#;"
+41 WRITE !,"PU11,19.3;LBcontroversion is based upon one of the nine reasons given#;"
+42 WRITE !,"PU11,19;LBbelow:#"
+43 DO ^OOPSPC71
+44 WRITE !,$CHAR(27),"&r0F",$CHAR(27),"%0A"
QUIT
