OOPSPC81 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-2 (PART 2) ;5/4/98
;;2.0;ASISTS;;Jun 03, 2002
EN1 ;
W !,"PU.5,16.4;LBa) Describe in detail the work performed by the employee. Identify@;"
W !,"PU11,16.4;LBc) Attach a record of the employee's absence from work caused@;"
W !,"PU1,16.1;LBfumes, chemicals, or other irritants or situations that the employ-@;"
W !,"PU11.5,16.1;LBby any similar disease or illness. Have the employee state the@;"
W !,"PU1,15.8;LBee was exposed to which allegedly caused the condition. State@;PU11.5,15.8;LBreason for each absence.@;"
W !,"PU1,15.5;LBthe nature, extent, and duration of the exposure, including hours@;"
W !,"PU11,15.4;LBd) Attach statements from each co-worker who has first-hand@;"
W !,"PU1,15.2;LBper days and days per week, requested above.@;PU11.5,15.1;LBknowledge about the employee's condition and its cause. (The@;"
W !,"PU.5,14.8;LBb) Attach copies of all medical reports (including x-ray reports and@;"
W !,"PU11.5,14.8;LBco-workers should state how such knowledge was obtained.)@;"
W !,"PU1,14.5;LBlaboratory data) on file for the employee.@;"
W !,"PU11,14.4;LBe) Review and comment on the accuracy of the employee's state-@;PU11.5,14.1;LBment requested above.@;"
W !,"PU.5,13.7;LBThe supervisor should also submit any other information or evidence pertinent @;"
W !,"LBto the merits of this claim.@;"
W !,"PU.5,13.5;PD22,13.5;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LBItem Explanations@;"
W !,"LB Some of the items on the form which may require further clarification are explained below.@;"
W !,"PU.5,13;PD22,13;PU.5,13;RA22,13.5;"
W !,"PU.5,12.5;LB14. Nature of the disease or illness@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU1,12.1;LBGive a complete description of the disease or illness. Specify@;"
W !,"PU1,11.8;LBthe left or right side if applicable (e.g., rash on left leg; carpal@;"
W !,"PU1,11.5;LBtunnel syndrome, right wrist).@;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
W !,"PU.5,10.8;LB19. Agency name and address of reporting office@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU1,10.4;LBThe name and address of the office to which correspondence@;"
W !,"PU1,10.1;LBfrom OWCP should be sent (If applicable, the address of the@;"
W !,"PU1,9.8;LBpersonnel or compensation office).@;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
W !,"PU.5,8.9;LB23. Name and address of physician first providing@;"
W !,"PU1,8.5;LBmedical care@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU1,8.1;LBThe name and address of the physician who first provided@;"
W !,"PU1,7.8;LBmedical care for this injury. If initial care was given by a@;"
W !,"PU1,7.5;LBnurse or other health professional (not a physician) in the@;"
W !,"PU1,7.2;LBemploying agency's health unit or clinic, indicate this on a@;"
W !,"PU1,6.9;LBseparate sheet of paper.@;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
W !,"PU11,12.5;LB24. First date medical care received@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11.5,12.2;LBThe date of the first visit to the physician listed in item 23.@;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
W !,"PU11,10.8;LB32. Employee's Retirement Coverage.@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11.5,10.4;LBIndicate which retirement system the employee is covered@;"
W !,"PU11.5,10.1;LBunder.@;"
W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
W !,"PU11,9.2;LB33. Was the injury caused by third party?@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU11.5,8.9;LBA third party is an individual or organization (other than the@;"
W !,"PU11.5,8.6;LBinjured employee or the Federal government) who is liable for@;"
W !,"PU11.5,8.3;LBthe disease. For instance, manufacturer of a chemical to which@;"
W !,"PU11.5,8;LBan emoloyee was exposed might be considered a third party if@;"
W !,"PU11.5,7.7;LBimproper instructions were given by the manufacturer for use of@;"
W !,"PU11.5,7.4;LBthe chemical.@;"
W !,"PU.5,6.2;PD22,6.2;PU.5,5.8;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmploying Agency - Required Codes@;"
W !,"PU.5,5.7;PD22,5.7;PU.5,5.7;RA22,6.2;"
W !,"PU.5,5.2;LBBox a (Occupation Code), Box b (Type Code), Box c@;"
W !,"PU.5,4.8;LB(Source Code), OSHA Site Code@;PU11,5.2;LBOWCP Agency Code@;"
W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,4.4;LBThe Occupational Safety and Health Administration (OSHA)@;"
W !,"PU11,4.8;LBThis is a four digit (or four digit two letter) code used by@;"
W !,"PU11,4.5;LBOWCP to identify the employing agency. The proper code@;"
W !,"PU11,4.2;LBmay be obtained from your personnel or compensation office,@;"
W !,"PU.5,4.1;LBrequires all employing agencies to complete these items when@;"
W !,"PU11,3.9;LBor by contacting OWCP.@;"
W !,"PU.5,3.8;LBreporting an injury. The proper codes may be found in OSHA@;"
W !,"PU.5,3.5;LBBooklet 2014, Record Keeping and Reporting Guidelines.@;"
W !,"PU.5,3;PD22,3;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
W !,"PU18.5,2.5;LBForm CA-2@;PU18.5,2.1;LBRev. Jan. 1997@;"
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HOOPSPC81 4992 printed Apr 09, 2024@20:44:55 Page 2
OOPSPC81 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-2 (PART 2) ;5/4/98
+1 ;;2.0;ASISTS;;Jun 03, 2002
EN1 ;
+1 WRITE !,"PU.5,16.4;LBa) Describe in detail the work performed by the employee. Identify@;"
+2 WRITE !,"PU11,16.4;LBc) Attach a record of the employee's absence from work caused@;"
+3 WRITE !,"PU1,16.1;LBfumes, chemicals, or other irritants or situations that the employ-@;"
+4 WRITE !,"PU11.5,16.1;LBby any similar disease or illness. Have the employee state the@;"
+5 WRITE !,"PU1,15.8;LBee was exposed to which allegedly caused the condition. State@;PU11.5,15.8;LBreason for each absence.@;"
+6 WRITE !,"PU1,15.5;LBthe nature, extent, and duration of the exposure, including hours@;"
+7 WRITE !,"PU11,15.4;LBd) Attach statements from each co-worker who has first-hand@;"
+8 WRITE !,"PU1,15.2;LBper days and days per week, requested above.@;PU11.5,15.1;LBknowledge about the employee's condition and its cause. (The@;"
+9 WRITE !,"PU.5,14.8;LBb) Attach copies of all medical reports (including x-ray reports and@;"
+10 WRITE !,"PU11.5,14.8;LBco-workers should state how such knowledge was obtained.)@;"
+11 WRITE !,"PU1,14.5;LBlaboratory data) on file for the employee.@;"
+12 WRITE !,"PU11,14.4;LBe) Review and comment on the accuracy of the employee's state-@;PU11.5,14.1;LBment requested above.@;"
+13 WRITE !,"PU.5,13.7;LBThe supervisor should also submit any other information or evidence pertinent @;"
+14 WRITE !,"LBto the merits of this claim.@;"
+15 WRITE !,"PU.5,13.5;PD22,13.5;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LBItem Explanations@;"
+16 WRITE !,"LB Some of the items on the form which may require further clarification are explained below.@;"
+17 WRITE !,"PU.5,13;PD22,13;PU.5,13;RA22,13.5;"
+18 WRITE !,"PU.5,12.5;LB14. Nature of the disease or illness@;"
+19 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+20 WRITE !,"PU1,12.1;LBGive a complete description of the disease or illness. Specify@;"
+21 WRITE !,"PU1,11.8;LBthe left or right side if applicable (e.g., rash on left leg; carpal@;"
+22 WRITE !,"PU1,11.5;LBtunnel syndrome, right wrist).@;"
+23 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
+24 WRITE !,"PU.5,10.8;LB19. Agency name and address of reporting office@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+25 WRITE !,"PU1,10.4;LBThe name and address of the office to which correspondence@;"
+26 WRITE !,"PU1,10.1;LBfrom OWCP should be sent (If applicable, the address of the@;"
+27 WRITE !,"PU1,9.8;LBpersonnel or compensation office).@;"
+28 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
+29 WRITE !,"PU.5,8.9;LB23. Name and address of physician first providing@;"
+30 WRITE !,"PU1,8.5;LBmedical care@;"
+31 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+32 WRITE !,"PU1,8.1;LBThe name and address of the physician who first provided@;"
+33 WRITE !,"PU1,7.8;LBmedical care for this injury. If initial care was given by a@;"
+34 WRITE !,"PU1,7.5;LBnurse or other health professional (not a physician) in the@;"
+35 WRITE !,"PU1,7.2;LBemploying agency's health unit or clinic, indicate this on a@;"
+36 WRITE !,"PU1,6.9;LBseparate sheet of paper.@;"
+37 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
+38 WRITE !,"PU11,12.5;LB24. First date medical care received@;"
+39 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+40 WRITE !,"PU11.5,12.2;LBThe date of the first visit to the physician listed in item 23.@;"
+41 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
+42 WRITE !,"PU11,10.8;LB32. Employee's Retirement Coverage.@;"
+43 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+44 WRITE !,"PU11.5,10.4;LBIndicate which retirement system the employee is covered@;"
+45 WRITE !,"PU11.5,10.1;LBunder.@;"
+46 WRITE !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
+47 WRITE !,"PU11,9.2;LB33. Was the injury caused by third party?@;"
+48 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+49 WRITE !,"PU11.5,8.9;LBA third party is an individual or organization (other than the@;"
+50 WRITE !,"PU11.5,8.6;LBinjured employee or the Federal government) who is liable for@;"
+51 WRITE !,"PU11.5,8.3;LBthe disease. For instance, manufacturer of a chemical to which@;"
+52 WRITE !,"PU11.5,8;LBan emoloyee was exposed might be considered a third party if@;"
+53 WRITE !,"PU11.5,7.7;LBimproper instructions were given by the manufacturer for use of@;"
+54 WRITE !,"PU11.5,7.4;LBthe chemical.@;"
+55 WRITE !,"PU.5,6.2;PD22,6.2;PU.5,5.8;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmploying Agency - Required Codes@;"
+56 WRITE !,"PU.5,5.7;PD22,5.7;PU.5,5.7;RA22,6.2;"
+57 WRITE !,"PU.5,5.2;LBBox a (Occupation Code), Box b (Type Code), Box c@;"
+58 WRITE !,"PU.5,4.8;LB(Source Code), OSHA Site Code@;PU11,5.2;LBOWCP Agency Code@;"
+59 WRITE !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,4.4;LBThe Occupational Safety and Health Administration (OSHA)@;"
+60 WRITE !,"PU11,4.8;LBThis is a four digit (or four digit two letter) code used by@;"
+61 WRITE !,"PU11,4.5;LBOWCP to identify the employing agency. The proper code@;"
+62 WRITE !,"PU11,4.2;LBmay be obtained from your personnel or compensation office,@;"
+63 WRITE !,"PU.5,4.1;LBrequires all employing agencies to complete these items when@;"
+64 WRITE !,"PU11,3.9;LBor by contacting OWCP.@;"
+65 WRITE !,"PU.5,3.8;LBreporting an injury. The proper codes may be found in OSHA@;"
+66 WRITE !,"PU.5,3.5;LBBooklet 2014, Record Keeping and Reporting Guidelines.@;"
+67 WRITE !,"PU.5,3;PD22,3;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
+68 WRITE !,"PU18.5,2.5;LBForm CA-2@;PU18.5,2.1;LBRev. Jan. 1997@;"
+69 QUIT
