Download As Word PDF Workers' Compensation Templates For Free

This form provides your supervisor and OWCP with interim medical reports containing information as to your ability to return to any type of work. Form CA-17 is designed to be filled out by the injured worker's supervisor and his/her treating physician to complete. It is split into two sections: A and B.

Form CA-7 is used to claim compensation for wage loss while in a leave without pay (LWOP) status due to disability or absence to obtain medical treatment (after continuation of pay (COP) period for traumatic injury cases).

There are two sides to the CA-17: Side A is completed by the employee's supervisor and Side B is completed by the employee's physician. A properly completed CA-17 should give the doctor an accurate picture of a worker's daily work duties so that accurate work restrictions can be noted.

When an injured worker has permanent loss of use of certain body parts or organs, s/he may request a schedule award by submitting a CA-7 Claim for Schedule Award and an impairment rating completed by her/his treating physician.

Instructions for Completing Form CA-7A Time Analysis. General: This form is used when claiming FECA compensation, including repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.

The employer is required to file an Employer's First Report of Injury or Illness [DWC FORM -1 (Rev. 10/05)] with the injured worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease.