OOPSPC80 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-2 (PART 1) ;5/4/98
;;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.2;SC0,22,0,29,1;"
W !,"DT@,1;SD1,277,2,1,4,10,5,0,6,2,7,23;"
W !,"PU.5,28.3;LBInstructions for Completing Form CA-2@;"
W !,"PU.5,28.1;PD22,28.1;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.7;LBComplete all items on your section of the form. If additional space is required @;"
W !,"LBto explain or clarify any point, attach a supplemental@;"
W !,"PU0.5,27.4;LBstatement to the form. In addition to the information requested on the form, both the employee @;"
W !,"LBand the supervisor are required to @;"
W !,"PU0.5,27.1;LBsubmit additional evidence as decribed below. If this evidence is not submitted @;"
W !,"LBalong with the form, the responsible party should@;"
W !,"PU0.5,26.8;LBexplain the reason for the delay and state when the additional evidence will be submitted.@;"
W !,"PU.5,26.6;PD22,26.6;PU.5,26.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmployee@;"
W !,"LB (or person acting on the employee's behalf)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,26.1;PD22,26.1;PU.5,26.1;FT10,10;RA22,26.6;"
W !,"PU0.5,25.7;LBComplete items 1 through 18 and submit the form to the employee's supervisor @;"
W !,"LBalong with the statement and medical reports described@;"
W !,"PU0.5,25.4;LBbelow. Be sure to obtain the Receipt of Notice of Disease or Illness completed @;"
W !,"LBby the supervisor at the time the form is submitted.@;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU0.5,25;LB1) Employee's statement@;"
W !,"PU11,25;LB2) Medical report@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU0.5,24.7;LBIn a separate narrative statement attached to the form the@;"
W !,"PU0.5,24.4;LBemployee must submit the following information:@;"
W !,"PU1,24;LBa) A detailed history of the disease or illness from the date it@;"
W !,"PU1.3,23.7;LBstarted.@;"
W !,"PU1,23.3;LBb) Complete details of the conditions of employment which are@;"
W !,"PU1.3,23;LBbelieved to be responsible for the disease or illness.@;"
W !,"PU1,22.6;LBc) A description of specific exposures to substances or stress-@;"
W !,"PU1.3,22.3;LBful conditions causing the disease or illness, including loca-@;"
W !,"PU1.3,22;LBtions where exposure or stress occurred, as well as the@;"
W !,"PU1.3,21.7;LBnumber of hours per day and days per week of such@;"
W !,"PU1.3,21.4;LBexposure or stress.@;"
W !,"PU1,21;LBd) Identification of the part of the body affected. (If disability is@;"
W !,"PU1.3,20.7;LBdue to a heart condition, give complete details of all@;"
W !,"PU1.3,20.4;LBactivities for one week prior to the attack with particular@;"
W !,"PU1.3,20.1;LBattention to the final 24 hours of such period.)@;"
W !,"PU1,19.7;LBe) A statement as to whether the employee ever suffered a@;"
W !,"PU1.3,19.4;LBsimilar condition. If so, provide full details of onset, history,@;"
W !,"PU1.3,19.1;LBand medical care received, along with names and addres-@;"
W !,"PU1.3,18.8;LBses of physicians rendering treatment.@;"
W !,"PU11.5,24.6;LBa) Dates of examination or treatment.@;"
W !,"PU11.5,24.2;LBb) History given to the physician by the employee.@;"
W !,"PU11.5,23.8;LBc) Detailed description of the physician's findings.@;"
W !,"PU11.5,23.4;LBd) Results of x-rays, laboratory tests, etc.@;"
W !,"PU11.5,23;LBe) Diagnosis.@;PU11.5,22.6;LBf) Clinical course of treatment.@;"
W !,"PU11.5,22.2;LBg) Physician's opinion as to whether the disease or illness@;"
W !,"PU11.8,21.9;LBwas caused or aggravated by the employment, along with@;"
W !,"PU11.8,21.6;LBan explanation of the basis for this opinion. (Medical@;"
W !,"PU11.8,21.3;LBreports that do not explain the basis for the physician's@;"
W !,"PU11.8,21;LBopinion are given very little weight in adjudicating the@;"
W !,"PU11.8,20.7;LBclaim.)@;SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20;LB3) Wage loss@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11.5,19.6;LBIf you have lost wages or used leave for this illness, Form@;PU11.5,19.3;LBCA-7 should also be submitted.@;"
W !,"PU.5,18.6;PD22,18.6;"
W !,"PU.5,18.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBSupervisor@;"
W !,"LB (Or appropriate official in the employing agency)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU.5,18.1;PD22,18.1;PU.5,18.1;RA22,18.6;"
W !,"PU.5,17.7;LBAt the time the form is received, complete the Receipt of Notice of Disease or Illness and give @;"
W !,"LBit to the employee. In addition to completing@;"
W !,"PU.5,17.4;LBitems 19 through 34, the supervisor is responsible for filling in the proper codes @;"
W !,"LBin shaded boxes a, b, and c on the front of the form. If@;"
W !,"PU.5,17.1;LBmedical expense or lost time is incurred or expected, the completed form @;"
W !,"LBmust be sent to OWCP within ten working days after it is@;"
W !,"PU.5,16.8;LBreceived. In a separate, narrative statement attached to the form, the supervisor must:@;"
D ^OOPSPC81
W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HOOPSPC80 5165 printed Apr 09, 2024@20:43:45 Page 2
OOPSPC80 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-2 (PART 1) ;5/4/98
+1 ;;2.0;ASISTS;;Jun 03, 2002
EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
+1 WRITE !,$CHAR(27),"E",$CHAR(27),"&l1E",$CHAR(27),"*c5952x7920Y",$CHAR(27),"%0B",$CHAR(27),"&s1#C"
+2 WRITE !,"IN;SP1;IP;PW.2;SC0,22,0,29,1;"
+3 WRITE !,"DT@,1;SD1,277,2,1,4,10,5,0,6,2,7,23;"
+4 WRITE !,"PU.5,28.3;LBInstructions for Completing Form CA-2@;"
+5 WRITE !,"PU.5,28.1;PD22,28.1;"
+6 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,27.7;LBComplete all items on your section of the form. If additional space is required @;"
+7 WRITE !,"LBto explain or clarify any point, attach a supplemental@;"
+8 WRITE !,"PU0.5,27.4;LBstatement to the form. In addition to the information requested on the form, both the employee @;"
+9 WRITE !,"LBand the supervisor are required to @;"
+10 WRITE !,"PU0.5,27.1;LBsubmit additional evidence as decribed below. If this evidence is not submitted @;"
+11 WRITE !,"LBalong with the form, the responsible party should@;"
+12 WRITE !,"PU0.5,26.8;LBexplain the reason for the delay and state when the additional evidence will be submitted.@;"
+13 WRITE !,"PU.5,26.6;PD22,26.6;PU.5,26.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmployee@;"
+14 WRITE !,"LB (or person acting on the employee's behalf)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+15 WRITE !,"PU.5,26.1;PD22,26.1;PU.5,26.1;FT10,10;RA22,26.6;"
+16 WRITE !,"PU0.5,25.7;LBComplete items 1 through 18 and submit the form to the employee's supervisor @;"
+17 WRITE !,"LBalong with the statement and medical reports described@;"
+18 WRITE !,"PU0.5,25.4;LBbelow. Be sure to obtain the Receipt of Notice of Disease or Illness completed @;"
+19 WRITE !,"LBby the supervisor at the time the form is submitted.@;"
+20 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;PU0.5,25;LB1) Employee's statement@;"
+21 WRITE !,"PU11,25;LB2) Medical report@;"
+22 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU0.5,24.7;LBIn a separate narrative statement attached to the form the@;"
+23 WRITE !,"PU0.5,24.4;LBemployee must submit the following information:@;"
+24 WRITE !,"PU1,24;LBa) A detailed history of the disease or illness from the date it@;"
+25 WRITE !,"PU1.3,23.7;LBstarted.@;"
+26 WRITE !,"PU1,23.3;LBb) Complete details of the conditions of employment which are@;"
+27 WRITE !,"PU1.3,23;LBbelieved to be responsible for the disease or illness.@;"
+28 WRITE !,"PU1,22.6;LBc) A description of specific exposures to substances or stress-@;"
+29 WRITE !,"PU1.3,22.3;LBful conditions causing the disease or illness, including loca-@;"
+30 WRITE !,"PU1.3,22;LBtions where exposure or stress occurred, as well as the@;"
+31 WRITE !,"PU1.3,21.7;LBnumber of hours per day and days per week of such@;"
+32 WRITE !,"PU1.3,21.4;LBexposure or stress.@;"
+33 WRITE !,"PU1,21;LBd) Identification of the part of the body affected. (If disability is@;"
+34 WRITE !,"PU1.3,20.7;LBdue to a heart condition, give complete details of all@;"
+35 WRITE !,"PU1.3,20.4;LBactivities for one week prior to the attack with particular@;"
+36 WRITE !,"PU1.3,20.1;LBattention to the final 24 hours of such period.)@;"
+37 WRITE !,"PU1,19.7;LBe) A statement as to whether the employee ever suffered a@;"
+38 WRITE !,"PU1.3,19.4;LBsimilar condition. If so, provide full details of onset, history,@;"
+39 WRITE !,"PU1.3,19.1;LBand medical care received, along with names and addres-@;"
+40 WRITE !,"PU1.3,18.8;LBses of physicians rendering treatment.@;"
+41 WRITE !,"PU11.5,24.6;LBa) Dates of examination or treatment.@;"
+42 WRITE !,"PU11.5,24.2;LBb) History given to the physician by the employee.@;"
+43 WRITE !,"PU11.5,23.8;LBc) Detailed description of the physician's findings.@;"
+44 WRITE !,"PU11.5,23.4;LBd) Results of x-rays, laboratory tests, etc.@;"
+45 WRITE !,"PU11.5,23;LBe) Diagnosis.@;PU11.5,22.6;LBf) Clinical course of treatment.@;"
+46 WRITE !,"PU11.5,22.2;LBg) Physician's opinion as to whether the disease or illness@;"
+47 WRITE !,"PU11.8,21.9;LBwas caused or aggravated by the employment, along with@;"
+48 WRITE !,"PU11.8,21.6;LBan explanation of the basis for this opinion. (Medical@;"
+49 WRITE !,"PU11.8,21.3;LBreports that do not explain the basis for the physician's@;"
+50 WRITE !,"PU11.8,21;LBopinion are given very little weight in adjudicating the@;"
+51 WRITE !,"PU11.8,20.7;LBclaim.)@;SD1,277,2,1,4,9,5,0,6,2,7,23;PU11,20;LB3) Wage loss@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+52 WRITE !,"PU11.5,19.6;LBIf you have lost wages or used leave for this illness, Form@;PU11.5,19.3;LBCA-7 should also be submitted.@;"
+53 WRITE !,"PU.5,18.6;PD22,18.6;"
+54 WRITE !,"PU.5,18.2;SD1,277,2,1,4,9,5,0,6,2,7,23;LBSupervisor@;"
+55 WRITE !,"LB (Or appropriate official in the employing agency)@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+56 WRITE !,"PU.5,18.1;PD22,18.1;PU.5,18.1;RA22,18.6;"
+57 WRITE !,"PU.5,17.7;LBAt the time the form is received, complete the Receipt of Notice of Disease or Illness and give @;"
+58 WRITE !,"LBit to the employee. In addition to completing@;"
+59 WRITE !,"PU.5,17.4;LBitems 19 through 34, the supervisor is responsible for filling in the proper codes @;"
+60 WRITE !,"LBin shaded boxes a, b, and c on the front of the form. If@;"
+61 WRITE !,"PU.5,17.1;LBmedical expense or lost time is incurred or expected, the completed form @;"
+62 WRITE !,"LBmust be sent to OWCP within ten working days after it is@;"
+63 WRITE !,"PU.5,16.8;LBreceived. In a separate, narrative statement attached to the form, the supervisor must:@;"
+64 DO ^OOPSPC81
+65 WRITE !,$CHAR(27),"&r0F",$CHAR(27),"%0A"
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