U.S. Department of Labor Claim for Compensation Office of Workers' Compensation Programs SECTION 1 EMPLOYEE PORTION a. Name of Employee First Last OMB No. Expires: Middle 1240-0046 /2011 c. OWCP File Number b. Mailing Address (Including City State, ZIP Code) d. Date of Injury Month Day Year e. Social Security Number E-Mail Address (Optional) SECTION 2 f. Telephone No./FAX No. Compensation is claimed for: Inclusive Date Range From To Yes Leave without pay Leave buy back Other wage loss; specify type, such as downgrade, loss of Type: night differential, etc. a. b. c. No No Yes Yes No Go to Section 3 Go to Section 3, and Complete Form CA-7b Go to Section 3 If intermittent, complete Form CA-7a, Time Analysis Sheet Schedule Award (Go to Section 4) d. Intermittent? You must report all earnings from employment (outside your federal job); include any employment for which you received a salary, wages, income, sales commissions, piecework, or payment of any kind during the period(s) claimed in Section 2. Include self-employment, involvement in business enterprises, as well as service with the military forces. Fraudulent concealment of employment or failure to report income may result in forfeiture of compensation benefits and/or criminal prosecution. Have you worked outside your federal job for the period(s) claimed in Section 2? SECTION 3 Name and Address of Business: Yes No Go to section 4 SECTION 4 Yes No SECTION 5 Name Name City Address State ZIP Code Dates Worked: Type of Work: Is this the first CA-7 claim for compensation you have filed for this injury? Complete Sections 5 through 7 and a Form SF-1199A, "Direct Deposit Sign-up" Has there been any change in your dependents, or has your direct deposit information changed, or has there been a claim filed with U.S. Civil Service Retirement, another federal retirement or disability law, or with the Department of Veterans Affairs since your last CA-7 claim? Yes - Complete Sections 5 through 7 or a new SF-1199A to reflect change(s) No - Complete Section 7 List your dependents (including spouse): Living with you? Social Security # Date of Birth Relationship Yes No a. Are you making support payments for a dependent shown above? Name b. Were support payments ordered by a court? Yes Address Yes No No For dependents not living with you , complete items a and b below. If Yes, support payments are made to: City State If Yes, attach copy of court order. ZIP Code SECTION 6 Yes a. Was/Will there be a claim made against a 3rd party? No b. Have you ever applied for or received disability benefits from the Department of Veterans Affairs? Yes Claim Number Full Address of VA Office Where Claim Filed Nature of Disability and Monthly Payment No c. Have you applied for or received payment under any Federal Retirement or Disability law? Yes Claim Number No SECTION 7 Date Annuity Began Amount of Monthly Payment Retirement System (CSRS, FERS, SSA, Other) CSRS FERS SSA Other I hereby make claim for compensation because of the injury sustained by me while in the performance of my duty for the United States. I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a felony conviction will result in termination of all current and future FECA benefits. Employee's Signature Date (Mo., day, year) American LegalNet, Inc. www.FormsWorkFlow.com Form CA-7 Rev. June 2005 Employing Agency Portion For first CA-7 claim sent, complete sections 8 through 15. For subsequent claims, complete sections 12 through 15 only. SECTION 8 Date of Injury: / Date: Additional Pay Type Show Pay Rate as of Base Pay / per $ per $ Grade: Step: Date Employee Stopped Work: / Date: / per $ Type per $ per $ Type Type per $ Additional Pay Type Additional Pay Type per $ per $ Step: Grade: Additional pay types include, but are not limited to: Night Differential (ND), Sunday Premium (SP), Holiday Premium (HP), Subsistence (SUB), Quarter (QTR), etc. (List each separately) SECTION 9 a. Does employee work a fixed 40-hour per week schedule? Yes No 1. If Yes, circle scheduled days: S M S TH W F T 2. If No, show scheduled hours for the two week pay period in which work stopped. Circle the day that work stopped. FOR EXAMPLE ONLY M S T W TH 4 6 6 6 to 5/20 8 WEEK From to 5/27 8 S From 4 From Yes Yes No No Yes No Yes Continuation of Pay (COP) Received (Show inclusive dates): / S F No SECTION 10 On date pay stopped, was employee enrolled in: c. Optional Life Insurance? a. Health Benefits under No Yes Code the FEHBP? d. A Retirement System? b. Basic Life Insurance? No Yes / / SECTION 12 Show pay status and inclusive dates for period(s) claimed: Class (D-Z only) Plan (Specify CSRS, FERS, Other) Yes Complete Time Analysis Sheet, Form CA-7a Intermittent? From To W TH to If No, would position have afforded employment for 11 months but for the injury? / T to b. Did employee work in position for 11 months prior to injury? SECTION 11 M S 6 WEEK 1 From 5/14 5/21 F No Intermittent? / To / / Yes No / Sick Leave From Annual Leave From / / To To To / / Yes No If intermittent, complete Form CA-7a, Time Analysis Sheet. / / / / Yes Yes No No If leave buy back, also submit completed Form CA-7b. / / Leave without Pay From / / Work From SECTION 13 Did employee return to work? / / If Yes, date Yes No If returned, did employee return to the pre-date-of-injury job, with the same number of hours and the same duties? Yes No If No, explain: SECTION 14 Remarks: SECTION 15 An employing agency official who knowingly certifies to any false statement, misrepresentation, or concealment of fact, with respect to this claim may also be subject to appropriate felony criminal prosecution. I certify that the information given above and that furnished by the employee on this form is true to the best of my knowledge, with any exceptions noted in Section 14, Remarks, above. Signature Date Title / (Agency Official) Name of Agency Date Claim Form Recieved from Employee / / If OWCP needs specific pay information, the person who should be contacted is: Name Telephone No. ( Title ) - Fax No. ( ) E-Mail Address American LegalNet, Inc. www.FormsWorkFlow.com / INSTRUCTIONS FOR COMPLETING FORM CA-7 If the employee does not quality for continuation of pay (for 45 days), the form should be completed and filed with the OWCP as soon as pay stops. The form should also be submitted when the employee reaches maximum improvement and claims a schedule award. If the employee is receiving continuation of pay and will continue to be disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day period. The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made. Collection of this information is required to obtain a benefit and is authorized by 20 C.F.R.10.106. EMPLOYEE (or person acting on the employee's behalf) - Complete sections 1 through 7 as directed and submit the form to the employee's supervisor. SUPERVISOR (or appropriate official in the employing agency) - Complete sections 8 through 15 as directed and promptly forward the form OWCP. EXPLANATIONS - Some of the items on the form which may require further clarification are explained below: Section Number Explanation 2d. Schedule Award Schedule awards are paid for permanent impairment to a member or function of the body. 5. List your dependents Your wife or husband is a dependent if he or she is living with you. A child is a dependent if he, or she either lives with you or receives support payments from you, and he or she: 1) is under 18, or 2) is between 18 and 23 and is a full-time student, or 3) is incapable of self-support due to physical or mental disability. 6a. Was/will there be a claim made against 3rd party? A third party is an individual or organization (other than the injured employee or the Federal government) who is liable for the injury. For instance, the driver of a vehicle causing an accident in which an employee is injured, the owner of a building where unsafe conditions cause an employee to fall, and a manufacturer who gave improper instructions for the use of a chemical to which an employee is exposed, could all be considered third parties to the injury. 8. Additional Pay ''Additional Pay'' includes night differential, Sunday premium, holiday premium, and any other type (such as hazardous duty or ''dirty work'' pay) regularly received by the employee, but does not include pay for overtime. If the amount of such pay varies from pay period to pay period (as in the case of holiday premium or a rotating shift), then the total amount of such pay earned during the year immediately prior to the date of injury or the date the employee stopped work (whichever is greater) should be reported. 11. Continuation of pay (COP) received If the injury was not a traumatic injury reported on Form CA-1, this item does not apply. 14. Remarks This space is used to provide relevant information which is not present else- where on the form. The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested information is required for the claimant to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C. 552a). Failure to furnish the requested information may delay the process, or result in an unfavorable decision or a reduced benefit. Public Burden Statement Public reporting burden forth is collection of information is estimated to average 13 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send them to the Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE American LegalNet, Inc. www.FormsWorkFlow.com Privacy Act In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are here by notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S .Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the processing and adjudication of the claim you filed under the FECA. American LegalNet, Inc. www.FormsWorkFlow.com