OOPSPC71 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-1 (PART 2) ;5/8/98
;;2.0;ASISTS;;Jun 03, 2002
EN1 ;
W !,"PU.5,18.5;LBIf the employing agency controverts COP, the employee should#;"
W !,"PU11,18.4;LBa) The disability was not caused by a traumatic injury.#;"
W !,"PU.5,18.2;LBbe notified and the reason for controversion explained to him or#;"
W !,"PU.5,17.9;LBher.#;"
W !,"PU11,17.7;LBb) The employee is a volunteer working without pay or for#;"
W !,"PU11.5,17.4;LBnominal pay, or a member of the office staff of a former#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,17.2;LB17) Agency name and address of reporting office#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11.5,17.1;LBPresident;#;"
W !,"PU.5,16.7;LBThe name and address of the office to which correspondence#;"
W !,"PU11,16.6;LBc) The employee is not a citizen or a resident of the United#;"
W !,"PU.5,16.4;LBfrom OWCP should be sent (if applicable, the address of the#;"
W !,"PU11.5,16.3;LBStates or Canada;#;"
W !,"PU.5,16.1;LBpersonnel or compensation office).#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,15.5;LB18) Duty station street address and zip code#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11,15.6;LBd) The injury occurred off the employing agency's premises and#;"
W !,"PU11.5,15.3;LBthe employee was not involved in official ""off premise"" duties;#;"
W !,"PU.5,15;LBThe address and zip code of the establishment where the#;"
W !,"PU.5,14.7;LBemployee actually works.#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,14.1;LB19) Employers Retirement Coverage.#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,13.7;LBIndicate which retirement system the employee is covered under.#;"
W !,"PU11,14.5;LBe) The injury was proximately caused by the employee's willful#;"
W !,"PU11.5,14.2;LBmisconduct, intent to bring about injury or death to self or#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LB30) Was injury caused by third party?#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11.5,13.9;LBanother person, or intoxication;#;"
W !,"PU.5,12.4;LBA third party is an individual or organization (other than the#;"
W !,"PU.5,12.1;LBinjured employee or the Federal government) who is liable for#;"
W !,"PU11,13.1;LBf) The injury was not reported on Form CA-1 within 30 days#;"
W !,"PU.5,11.8;LBthe injury. For instance, the driver of a vehicle causing an#;"
W !,"PU11.5,12.8;LBfollowing the injury;#;"
W !,"PU.5,11.5;LBaccident in which an employee is injured, the owner of a#;"
W !,"PU.5,11.2;LBbuilding where unsafe conditions cause an employee to fall, and#;"
W !,"PU11,12.1;LBg) Work stoppage first occurred 45 days or more following#;"
W !,"PU.5,10.9;LBa manufacturer whose defective product causes an employee's#;"
W !,"PU11.5,11.8;LBthe injury;#;"
W !,"PU.5,10.6;LBinjury, could all be considered third parties to the injury.#;"
W !,"PU11,11.1;LBh) The employee initially reported the injury after his or her#;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,9.8;LB32) Name and address of physician first providing#;PU.5,9.4;LBmedical care#;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11.5,10.8;LBemployment was terminated; or#;"
W !,"PU11,10.1;LBi) The employee is enrolled in the Civil Air Patrol, Peace Corps,#;"
W !,"PU.5,8.9;LBThe name and address of the physician who first provided#;"
W !,"PU11.5,9.8;LBYouth Conservation Corps, Work Study Programs, or other#;"
W !,"PU.5,8.6;LBmedical care for this injury. If initial care was given by a nurse#;"
W !,"PU11.5,9.5;LBsimilar groups.#;"
W !,"PU.5,8.3;LBor other health professional (not a physician) in the employing#;"
W !,"PU.5,8;LBagency's health unit or clinic, indicate this on a separate sheet#;"
W !,"PU.5,7.7;LBof paper.#;"
W !,"PU.5,6.6;EA21,7.1;RA21,7.1;PU.6,6.7;SD1,277,2,1,4,9,5,0,6,2,7,23;"
W !,"PU.6,6.7;LBEmploying Agency - Required Codes#;"
W !,"PU.5,6.2;LBBox a (Occupation Code), Box b (Type Code),#;"
W !,"PU.5,5.8;LBBox c (Source Code), OSHA Site Code#;PU11,6.2;LBOWCP Agency Code#;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11,5.6;LBThis is a four-digit (or four digit plus two letter) code used by#;"
W !,"PU.5,5.3;LBThe Occupational Safety and Health Administration (OSHA)#;"
W !,"PU11,5.3;LBOWCP to identify the employing agency. The proper code may#;"
W !,"PU.5,5;LBrequires all employing agencies to complete these items when#;"
W !,"PU11,5;LBbe obtained from your personnel or compensation office, or by#;"
W !,"PU.5,4.7;LBreporting an injury. The proper codes may be found in OSHA#;"
W !,"PU11,4.7;LBcontacting OWCP.#;"
W !,"PU.5,4.4;LBBooklet 2014, Recordkeeping and Reporting Guidelines.#;"
W !,"PU.5,4;PD21,4;PU18,3.5;LBForm CA-1#;PU18,3;LBRev. Apr. 1999#;"
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HOOPSPC71 4716 printed Nov 22, 2024@16:49:43 Page 2
OOPSPC71 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-1 (PART 2) ;5/8/98
+1 ;;2.0;ASISTS;;Jun 03, 2002
EN1 ;
+1 WRITE !,"PU.5,18.5;LBIf the employing agency controverts COP, the employee should#;"
+2 WRITE !,"PU11,18.4;LBa) The disability was not caused by a traumatic injury.#;"
+3 WRITE !,"PU.5,18.2;LBbe notified and the reason for controversion explained to him or#;"
+4 WRITE !,"PU.5,17.9;LBher.#;"
+5 WRITE !,"PU11,17.7;LBb) The employee is a volunteer working without pay or for#;"
+6 WRITE !,"PU11.5,17.4;LBnominal pay, or a member of the office staff of a former#;"
+7 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,17.2;LB17) Agency name and address of reporting office#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+8 WRITE !,"PU11.5,17.1;LBPresident;#;"
+9 WRITE !,"PU.5,16.7;LBThe name and address of the office to which correspondence#;"
+10 WRITE !,"PU11,16.6;LBc) The employee is not a citizen or a resident of the United#;"
+11 WRITE !,"PU.5,16.4;LBfrom OWCP should be sent (if applicable, the address of the#;"
+12 WRITE !,"PU11.5,16.3;LBStates or Canada;#;"
+13 WRITE !,"PU.5,16.1;LBpersonnel or compensation office).#;"
+14 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,15.5;LB18) Duty station street address and zip code#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+15 WRITE !,"PU11,15.6;LBd) The injury occurred off the employing agency's premises and#;"
+16 WRITE !,"PU11.5,15.3;LBthe employee was not involved in official ""off premise"" duties;#;"
+17 WRITE !,"PU.5,15;LBThe address and zip code of the establishment where the#;"
+18 WRITE !,"PU.5,14.7;LBemployee actually works.#;"
+19 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,14.1;LB19) Employers Retirement Coverage.#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+20 WRITE !,"PU.5,13.7;LBIndicate which retirement system the employee is covered under.#;"
+21 WRITE !,"PU11,14.5;LBe) The injury was proximately caused by the employee's willful#;"
+22 WRITE !,"PU11.5,14.2;LBmisconduct, intent to bring about injury or death to self or#;"
+23 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LB30) Was injury caused by third party?#;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+24 WRITE !,"PU11.5,13.9;LBanother person, or intoxication;#;"
+25 WRITE !,"PU.5,12.4;LBA third party is an individual or organization (other than the#;"
+26 WRITE !,"PU.5,12.1;LBinjured employee or the Federal government) who is liable for#;"
+27 WRITE !,"PU11,13.1;LBf) The injury was not reported on Form CA-1 within 30 days#;"
+28 WRITE !,"PU.5,11.8;LBthe injury. For instance, the driver of a vehicle causing an#;"
+29 WRITE !,"PU11.5,12.8;LBfollowing the injury;#;"
+30 WRITE !,"PU.5,11.5;LBaccident in which an employee is injured, the owner of a#;"
+31 WRITE !,"PU.5,11.2;LBbuilding where unsafe conditions cause an employee to fall, and#;"
+32 WRITE !,"PU11,12.1;LBg) Work stoppage first occurred 45 days or more following#;"
+33 WRITE !,"PU.5,10.9;LBa manufacturer whose defective product causes an employee's#;"
+34 WRITE !,"PU11.5,11.8;LBthe injury;#;"
+35 WRITE !,"PU.5,10.6;LBinjury, could all be considered third parties to the injury.#;"
+36 WRITE !,"PU11,11.1;LBh) The employee initially reported the injury after his or her#;"
+37 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,9.8;LB32) Name and address of physician first providing#;PU.5,9.4;LBmedical care#;"
+38 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11.5,10.8;LBemployment was terminated; or#;"
+39 WRITE !,"PU11,10.1;LBi) The employee is enrolled in the Civil Air Patrol, Peace Corps,#;"
+40 WRITE !,"PU.5,8.9;LBThe name and address of the physician who first provided#;"
+41 WRITE !,"PU11.5,9.8;LBYouth Conservation Corps, Work Study Programs, or other#;"
+42 WRITE !,"PU.5,8.6;LBmedical care for this injury. If initial care was given by a nurse#;"
+43 WRITE !,"PU11.5,9.5;LBsimilar groups.#;"
+44 WRITE !,"PU.5,8.3;LBor other health professional (not a physician) in the employing#;"
+45 WRITE !,"PU.5,8;LBagency's health unit or clinic, indicate this on a separate sheet#;"
+46 WRITE !,"PU.5,7.7;LBof paper.#;"
+47 WRITE !,"PU.5,6.6;EA21,7.1;RA21,7.1;PU.6,6.7;SD1,277,2,1,4,9,5,0,6,2,7,23;"
+48 WRITE !,"PU.6,6.7;LBEmploying Agency - Required Codes#;"
+49 WRITE !,"PU.5,6.2;LBBox a (Occupation Code), Box b (Type Code),#;"
+50 WRITE !,"PU.5,5.8;LBBox c (Source Code), OSHA Site Code#;PU11,6.2;LBOWCP Agency Code#;"
+51 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU11,5.6;LBThis is a four-digit (or four digit plus two letter) code used by#;"
+52 WRITE !,"PU.5,5.3;LBThe Occupational Safety and Health Administration (OSHA)#;"
+53 WRITE !,"PU11,5.3;LBOWCP to identify the employing agency. The proper code may#;"
+54 WRITE !,"PU.5,5;LBrequires all employing agencies to complete these items when#;"
+55 WRITE !,"PU11,5;LBbe obtained from your personnel or compensation office, or by#;"
+56 WRITE !,"PU.5,4.7;LBreporting an injury. The proper codes may be found in OSHA#;"
+57 WRITE !,"PU11,4.7;LBcontacting OWCP.#;"
+58 WRITE !,"PU.5,4.4;LBBooklet 2014, Recordkeeping and Reporting Guidelines.#;"
+59 WRITE !,"PU.5,4;PD21,4;PU18,3.5;LBForm CA-1#;PU18,3;LBRev. Apr. 1999#;"
+60 QUIT
