OBJECTIVESIdentify the forms required for filing an injury

or illnessDiscuss the appropriate responses on the

supervisor portion of the claim formDiscuss the importance of communication

with the Workers’ Compensation StaffIdentify documents used to authorize medical

treatment and duty status reports

ENTITLEMENTSRight to file a CA-1 (injury) and CA-2 (illness),

to apply for compensation

Entitlement includes the option to receive medical treatment by either the VA Occupational Health Unit or their primary care provider

Authorized to designate representation

DEFINITIONSFECA- Federal Employees’ Compensation ActOWCP-Office of Workers’ Compensation

ProgramsEmployer or Agency - refers to officers and

employees of an employer having responsibility for the supervision, direction and control of employees

Representative-An individual or law firm properly authorized by a claimant in writing to act for the claimant in connection with a claim

CA-1 (cont)Employee must give notice in writing using

form CA-1Review page one of the form ensuring it

includes a detailed description of the injuryComplete and sign page two of the form

within 2-3 daysComplete Receipt of Notice attached to CA1

and provide to employee

CA-1 (cont)Submit completed form to Workers’

Compensation OfficeMedical care authorized if appropriateAdvise the employee if COP will be

controvertedAdvise the employee of their responsibility to

submit Prima Facie medical evidence of disability within 10 calendar days

Additional Forms Completed With the CA-1Release of InformationElection of PhysicianFirst Script CardEmployee Responsibilities10.330

Sample Release of Information Form

I hereby authorize release of medical information related to my claim for workers’ compensation benefits relating to my injury/illness of _________________________________________, which occurred on ____________(date)_____________. Please provide medical information concerning my injury/illness to the address/office below to be used in processing my claim for benefits under the Federal Employees’ Compensation Act (FECA).

Signature: ____________________________________ Date: _________________________

Name: _________________________________ Date of Birth: ________________________

SSN: (last 4) ___________

Please return requested information to:

Workers’ Compensation Staff VA Medical Center 123 NE Main St. City, State, Zip

Fax: ___________________

If additional information is needed, please call: ____________________________________

Sample Election of Physician Form

Name: _________________________________ Date of Injury: ________________________

I have read and understand the Employee Bill of Rights provided in the Automated Safety Incident Surveillance and Tracking System (ASISTS) in conjunction with completion of Form CA-1/CA-2 for this injury. I understand I have the right to choose my initial choice of physician to provide my medical care/treatment for the above injury.

_______Occupational Health Unit, VA Medical Center

_______Private Physician:

Name: _______________________________________

Medical Facility: _______________________________

Address: _____________________________________

City, State and Zip: _____________________________

Phone: (____)_____________ Fax: (____) _________

First appointment scheduled for __________________(date) at __________________(time).

Chiropractic services are limited to specific treatment(s) to correct a spinal subluxation as demonstrated/diagnosed by X-ray to exist.

______I decline any medical care/treatment at this time. I understand this may affect future authorization for medical benefits in relation to this injury/condition.

______Employees should request any change in treating physician in writing to the U.S. Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP), and explain the reason for the request.

Employee Signature: ______________________________ Date: _____________________

Print Name: ________________________________________________________________

Forward this signed original to the Workers’ Compensation Program staff for filing in the case file.

Employee Responsibilities – Traumatic Injury The Federal Workers' Compensation Program is a benefit for Federal Employees. It is your responsibility to stay actively involved in every facet of the program. Follow time and leave policy by requesting leave from your supervisor for all injury related absences. Keep your supervisor and this office informed of all injury related lost time and restrictions. Provide a return to work statement indicating your current work status to your supervisor and this office following each medical appointment. If you are given any work restrictions make sure they are specific, if the restrictions are not specific you will be requested to obtain clarification from your physician. In order to receive Continuation of Pay (COP) for injury related absences you must provide our office supporting medical documentation from your physician. If we do not receive supporting medical documentation COP will not be authorized. Eligibility for receipt of COP is for a period of up to 45 days. Following the period of COP eligibility you may claim compensation for injury related lost time from work by completing form CA-7, Claim for Compensation. To avoid an interruption of pay for disability extending beyond the COP period please contact our office by the 30th day of disability to obtain form CA7 and instruction for completion of the form. Provide our office a copy of the medical note for all treatment received for your injury. Keep us informed of all appointments and any tests that the doctor has scheduled. Be advised Chiropractor care is limited to specific treatment(s) to correct a spinal subluxation as demonstrated/diagnosed by x-ray to exist. Make sure that your physician of choice accepts Federal workers’ compensation and is enrolled with ACS, Department of Labor’s bill payment and medical authorization program. This also pertains to pharmacies, physical therapy and durable medical equipment.

Advise your physician that your employing agency will accommodate work restrictions by providing a limited duty assignment. Department of Labor regulations provide employees must seek work and any employee who refuses to seek or accept suitable work will not be entitled to compensation. All medical reports must be signed by a physician. A physician's assistant, nurse or nurse practitioner are not considered physicians and must be co-signed by a physician. Please be advised the medical evidence submitted from your physician must have a clear diagnosis and pain is considered to be only a symptom and not a diagnosis. If your doctor indicates that you require surgery, notify us immediately. It is the responsibility of the doctor's office to request authorization for the surgery through ACS. Once your surgery has been scheduled contact our office regarding your leave options and instruction for claiming compensation for lost time from work. I have received my First Script benefit card. I have received a copy of What are the Requirements for Medical Reports. If you have additional questions or concerns please contact our office at 123-456-7890. I have received a copy of this employee responsibility form: Signature_______________________________________________ Date ___________________ Printed Name ___________________________________________

Medical Reports Sec. 10.330 What are the requirements for medical reports? In all cases reported to OWCP, a medical report from the attending physician is required. This report should include: (a) Dates of examination and treatment; (b) History given by the employee; (c) Physical findings; (d) Results of diagnostic tests; (e) Diagnosis; (f) Course of treatment; (g) A description of any other conditions found but not due to the claimed injury; (h) The treatment given or recommended for the claimed injury; (i) The physician's opinion, with medical reasons, as to causal relationship between the diagnosed condition(s) and the factors or conditions of the employment; (j) The extent of disability affecting the employee's ability to work due to the injury; (k) The prognosis for recovery; and (l) All other material findings.

The report may be made in narrative form on the physician's letterhead/stationery. This report, and any other medical report, work statement and/or disability for work statement must be signed (or counter-signed) by a qualified physician. NOTE: Employees are responsible for advising their physician that limited duty can and will be made available within _____________VA Medical Center based on the physician’s specific recommendations. It is the policy of ___________VA Medical Center that all injured employees will be accommodated unless totally disabled for any and all work. Duties need not be within or associated with the employee’s current position.

CA-2 (cont)Review page one of the form ensuring it

includes a detailed description of condition and relationship to employment

Complete and sign page two of the form within 2-3 days

Complete Receipt of Notice attached to CA2 and provide to employee

Submit completed form to Workers’ Compensation Office

CA-35 ChecklistsOccupational Disease (generic)Work-Related Hearing LossAsbestos-Related IllnessWork-Related Coronary/Vascular ConditionWork-Related Skin DiseaseWork-Related Pulmonary Illness (not

asbestosis)Work-Related Psychiatric IllnessWork-Related Carpal Tunnel Syndrome

CA-2a, Notice of RecurrenceRecurrence of Medical Condition

Documented need for additional medical treatment after release from treatment for the work-related injury.

Recurrence of DisabilitySpontaneous return of the symptoms of a

previous injury or occupational disease without an intervening cause.

CA-2a (cont)

Employee completes and signs page one of the form

Supervisor will review employee’s portion of the form and complete page two

Treated the same as a CA2 in that it is not considered work-related unless DOL accepts the recurrence.

CA-5 and CA-5b (cont)Benefits may be paid to eligible dependents

of an employee whose death results from an injury sustained in the performance of duty.

CA-16, Authorization for Examination and/or Treatment

Complete the form with 4 hours of requestMay refuse to issue if more than a week has

passed since the injury

CA-17, Duty Status Report

To obtain interim medical reports Issued with the CA-16Supervisor completes the agency portion of

the formMay send to the physician at reasonable

intervalsMonitor employee’s medical status and

ability to return to limited or full duty

Memorandum

Date: From: Workers’ Compensation Program Office or Supervisor (Name/Title)

Subj: Transitional Duty Assignment

To: Employee (Name/Title) Thru:

1. The purpose of this memorandum is to inform you that the following transitional duty assignment is offered to you as a result of your work-related injury of (Date of Injury). Your physician has indicated that you may return to work on (Date), with the following medical restrictions:

List Restrictions. List Restrictions. List Restrictions.

(Reference medical note/Form CA-17, etc., dated XX-XX-XX.)

2. A transitional duty assignment that meets your physical restrictions has been identified and is available. Effective (Date), you will be given a transitional duty assignment on your unit. Your tour of duty will be (List days of week and tour of duty hours). You will retain your current salary of (insert grade/step and salary) during this assignment. This transitional duty assignment will continue until your physician provides medical evidence to support a change in your restrictions or the service no longer has transitional work available, at which time a new transition duty assignment will be issued.

3. Your transitional duty assignments will consist of the following:

List duty assignments. List duty assignments.

Physical requirements: (List requirements) (Example: You will be required to sit for 4 hours intermittently and/or walk 4 hours intermittently. No lifting over 5 pounds. No pushing or pulling or bending. You may sit or stand within the immediate work area.

4. At no time are you to engage in any activity that could harm or aggravate your condition. It will be your responsibility to communicate your restrictions to anyone who may inadvertently make an assignment that exceeds these restrictions. You are to promptly provide your supervisor any and all physician statements and/or changes in restrictions that may impact your ability to perform your transitional duty assignment.

5. Please be advised that you are obligated under federal regulations to work in an available transitional duty assignment that meets your medical restrictions. If you refuse to accept the employment offer or to perform the transitional duty assignment, it may result in termination of your workers’ compensation benefits. In addition, any resulting absence may be charged as

Absent Without Leave (AWOL), and an administrative action may be initated. Please indicate your acceptance or declination of this transitional duty assignment as indicated below.

6. We hope that this assignment will provide you with sufficient time to recover from your work injury while also making available gainful employment and continued income. If you have any questions concerning this matter you may contact me at (phone number).

(Workers’ Compensation or Supervisor Name/Signature) cc: Workers’ Compensation Program Manager U.S. Department of Labor (DOL)/Office of Workers’ Compensation Programs (OWCP) ____________________________________________________________________________ __________ I accept the transitional duty assignment described above. __________ I decline the transitional duty assignment as described above for the following

reason(s): ____________________________________________________________________________ ____________________________________________________________________________ I understand that acceptance or refusal of this transitional duty assignment must be provided to the DOL OWCP. In accordance with Title 5, USC 8106(c), a partially disabled employee who (2) “refuses or neglects to work after suitable work is offered to, procured by, or secured for him; is not entitled to compensation.” ____________________________________________________ Employee Signature and Date

Yvette Talley______________________________________________________________ To: 1st Level Supervisor; 2nd Level Supervisor CC: My Supervisor; Payroll Supervisor; Safety Manager; Service Timekeeper Subject: COP-(Initials) 2012-00001 As a result of claim of traumatic injury on Month, Day, Year the following absences are authorized for charge to COP (unless otherwise indicated) as elected on CA-1 by First MI Last. 3/1/11, Date of Injury, Authorized Absence (2:30 pm - 4:30 pm/2 hrs) 3/7/11 (8:00 am-12:00 noon/4 hours/appt) 3/18/11 thru 3/21/11 Total Cumulative COP= 5 calendar days Note: Additional absences possible. COP entitlement period expected to end on 4/16/11. Related absences AFTER 4/16/11 should be charged to appropriate leave and/or leave without pay (LWOP) Yvette Talley FWCP Specialist, VISN 9 Robley Rex VA Medical Center Louisville, KY 502-287-6175 Fax 502-287-6978 Confidentiality Note: This e-mail is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. Dissemination, distribution or copying of this e-mail or the information herein by anyone other than the intended recipient is prohibited. If you have received this e-mail in error, please notify the sender by reply e-mail and destroy the original message and all copies

Yvette Talley______________________________________________________________ To: Supervisor; Service Chief CC: My Supervisor; HR POC; Safety Manager; Occupational Health Subject: OWCP Decision- (Initials) By copy of letter dated Month, Day, Year to FIRST MI LAST, and received by FWCP Office on Month, Day, Year, the U.S. Department of Labor, OWCP, has advised this office the claim for traumatic injury on Month, Day, Year has been denied due to insufficient evidence. Medical treatment at OWCP expense is not authorized and prior authorization, if any, is hereby terminated. Employee was furnished appeal rights with this notice, but to date has not exercised any appeal through this office. Employee has returned to full duty relative to the claimed injury/condition. If you have any questions or concerns regarding this message, please do not hesitate to contact this office at ext. xxxx. Yvette Talley FWCP Specialist, VISN 9 Robley Rex VA Medical Center Louisville, KY 502-287-6175 Fax 502-287-6978 Confidentiality Note: This e-mail is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. Dissemination, distribution or copying of this e-mail or the information herein by anyone other than the intended recipient is prohibited. If you have received this e-mail in error, please notify the sender by reply e-mail and destroy the original message and all copies.

Yvette Talley______________________________________________________________ To: Supervisor; Service Chief CC: My Supervisor; HR POC; Safety Manager; Occupational Health Subject: OWCP Decision- (Initials) By copy of letter dated Month, Day, Year to FIRST MI LAST, and received by FWCP Office on Month, Day, Year, the U.S. Department of Labor, OWCP, has advised this office the claim for traumatic injury on Month, Day, Year has been denied due to insufficient evidence. Medical treatment at OWCP expense is not authorized and prior authorization, if any, is hereby terminated. Employee was furnished appeal rights with this notice, but to date has not exercised any appeal through this office. Employee is on limited duty relative to the claimed injury/condition, however, any coordination involving work capacity of this employee should be addressed with Human Resources Management Service as s/he is not covered by OWCP and is not entitled to benefits under the Federal Employees’ Compensation Act (FECA). If you have any questions or concerns regarding this message, please do not hesitate to contact this office at ext. xxxx. Yvette Talley FWCP Specialist, VISN 9 Robley Rex VA Medical Center Louisville, KY 502-287-6175 Fax 502-287-6978 Confidentiality Note: This e-mail is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. Dissemination, distribution or copying of this e-mail or the information herein by anyone other than the intended recipient is prohibited. If you have received this e-mail in error, please notify the sender by reply e-mail and destroy the original message and all copies.