FederalCOUNTY OF Notice of Employee's COURT U.S. Department of Labor Traumatic. Injury .and .Claim . for . . . . . . . . . . . . . . . . . Employment .Standards Administration ... ...... .... ...... ... ......... . Office of Workers' Compensation Programs : Continuation of Pay/Compensation Index No. Employee: Please complete all boxes 1 - 15 below. Do not complete shaded areas. : Calendar Witness: Complete bottom section 16. Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c. Employee Data 1. Name of employee (Last, First, Middle) 3. Date of birth Mo. Day Yr. : Plaintiff(s) JUDICIAL SUBPOENA 2. Social Security Number -against4. Sex Male No. : 5. Home telephone : Female 6. Grade as of date of injury 7. Employee's home mailing address (Include city, state, and ZIP code) Level Step 8. Dependents Wife, Husband Children under 18 years Other : Defendant(s) : ...................................................... Description of Injury 9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine) THE PEOPLE OF 10. Date injury occurred Time Mo. Day Yr. THE STATE OF Date of this notice 11. NEW YORK TO a.m. p.m. 12. Employee's occupation Mo. Day Yr. 13. Cause of injury (Describe what happened and why) GREETINGS: a. Occupation code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before b. Type code c. Source code , the Honorable at the Court located at County of OWCP Use - NOI Code in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Employee Signature 14. Nature of injury (Identify both the injury and the part of body, e.g., fracture of left leg) 15. I certify, under penalty of law, that the injury described above was sustained in performance of duty as an employee of the United States Government and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication. I hereby claim medical treatment, if needed, and the following, as checked below, while disabled for work: a. Continuation Your failure to comply with 45 days and compensation for wage loss contemptfor work continues of regular pay (COP) not to exceed this subpoena is punishable as a if disability of court and will make you liable to the party on If my claim is denied, understand was issued for a maximum penalty of $50 to si all beyond 45 days. whose behalf thisI subpoena that the continuation of my regular pay shall be chargedand ck damages sustained as a or annual leave, or failure to comply. result of your be deemed an overpayment within the meaning of 5 USC 5584. b. Sick and/or Annual Leave Witness, Honorable , one to the Justices I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency)of furnish any desired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative). Court in County, day of , 20 This authorization also permits any official representative of the Office to examine and to copy any records concerning me. Signature of employee or person acting on his/her behalf of the Date Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation (Attorney must sign above and type name below) 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. Have your supervisor complete the receipt attached to this form and return it to you for your records. Witness Statement 16. Statement of witness (Describe what you saw, heard, or know about this injury) Attorney(s) for Office and P.O. Address Name of witness Address Signature of witness City Date signed Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: State ZIP Code Form CA-1 Rev. Apr. 1999 American LegalNet, Inc. www.USCourtForms.com COURT Official Supervisor's Report: Please complete information requested below: COUNTY OF Supervisor's. Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 17. Agency name and address of reporting office (include city, state, and zip code) ......... : Index No. OWCP Agency Code : : Plaintiff(s) 18. Employee's duty station (Street address and -againstZIP code) 20. Regular work hours From: 22. Date of Injury 25. Date pay stopped a.m. p.m. To: JUDICIAL SUBPOENA FERS a.m. p.m. 21. Regular work schedule : Sun. Mon. Yr. THE PEOPLE OF 26. Date Mo. Day Yr. 45 day period began THE STATE OF NEW YORK 28. Was employee injured in performance of duty? Tues. Mo. Day Wed. Yes 27. Date returned to work Thurs. Fri. Yr. work received Day ZIP Code : Other, (identify) Defendant(s) : . .Mo. . .Day . .Yr.. . . . . . . . 23..Date . . . . Mo.. . Day . . . . . . . . . 24..Date . . . .. .. . . . notice ... . . . . . Yr. . . stopped ... Mo. OSHA Site Code : 19. Employee's retirement coverage CSRS Calendar No. a.m. p.m. Time: Mo. Day Sat. Yr. a.m. p.m. Time: No (If "No," explain) TO 29. Was injury caused by employee's willful misconduct, intoxication, or intent to injure self or another? Yes (If "Yes," explain) No GREETINGS: 30. Was injury caused 31. Name and address of third party (Include city, state, and ZIP code) by third party? Yes No WE COMMAND YOU, that all business and excuses being laid aside, the"No," at the Court (If Honorable go to located at County of item 32.) you and each of you attend before , in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 32. Name and address of physician first providing medical care (Include city, state, ZIP code) 33. First date Mo. medical care received Day Yr. 34. Do medical Yes No Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to reports show employee is the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a disabled for work? result of your failure to comply. 35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses? Witness, Honorable Court in County, day of , 20 36. If the employing agency controverts continuation of pay, state the reason in detail. Yes No (If "No," explain) , one of the Justices of the 37. Pay rate when employee stopped work $ Per Signature of Supervisor and Filing Instructions (Attorney must sign above and type name below) 38. A supervisor who knowingly certifies to any false statement, misrepresentation, concealment of fact, etc., in respect of 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 the reverse of this form is true to the best of my Attorney(s) for knowledge with the following exception: Name of supervisor (Type or print) Signature of supervisor Date Office Supervisor's Title Office phone 39. Filing instructions and P.O. Address Telephone No.: No lost time and no medical expense: Place this form in employee's medical folder (SF-66-D) No lost time, medical expense incurred or expected: forward this form to OWCP Facsimile No.: Lost time covered by leave, LWOP, or COP: forward this form to OWCP E-Mail Address: First Aid Injury Form CA-1, Mobile Tel. No.: Rev. Apr. 1999 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Instructions for Completing Form CA-1 : Index No. Calendar No. Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental statement to the form. Some of the items on the form which may require further clarification are explained below. Plaintiff(s) Employee (Or person acting on the employees' behalf) 13) Cause of injury -against- JUDICIAL SUBPOENA : 15) Election of COP/Leave Describe in detail how and why the injury occurred. Give appropriate details (e.g.: if you fell, how far did you fall and in what position did you land?) 14) Nature of Injury Give a complete description of the condition(s) resulting from your injury. Specify the right or left side if applicable (e.g., fractured left . . . cut . . . . . .index . . . . . . . . . . . . . . . . . . . . leg: . . on right . . . finger). : If you are disabled for work as a result of this injury and filed : CA-1 within thirty days of the injury, you may be entitled to receive continuation of pay (COP) from your employing agency. COP is paid for up to 45 calendar days of disability, and is not charged : against sick or annual leave. If you elect sick or annual leave you may not claim compensation to repurchase leave used Defendant(s) the 45 days of COP entitlement. during : .................... Supervisor At the time the form is received, complete the receipt of notice of THE PEOPLE OF THE STATE OF NEW YORK injury and give it to the employee. In addition to completing items 17 through 39, the supervisor is responsible for obtaining the witness statement in Item 16 and for filling in the proper codes TO in shaded boxes a, b, and c on the front of the form. If medical expense or lost time is incurred or expected, the completed form should be sent to OWCP within 10 working days after it is received. The supervisor should also submit any other information or GREETINGS: evidence pertinent to the merits of this claim. 33) First date medical care received The date of the first visit to the physician listed in item 31. 36) If the employing agency controverts continuation of pay, state the reason In detail. COP may be controverted (disputed) for any reason; however, the employing agency may refuse to pay COP only if the controversion is based upon one of the nine reasons given below: a) The disability was not caused by a traumatic injury. If the employing agency controverts COP, the employee should WE COMMAND YOU, that all business be notified and the reason for controversion explained to him or the Honorable her. and excuses being laid volunteer working without of you attend before b) The employee is a aside, you and each pay or for , at the nominal pay, orCourt a member of the office staff of a former President; located at County of c) The employee is not a citizen or a resident of the United in room , on the day of , 20 , at o'clock in the noon, and at any recessed The name and address of the office to which correspondence States or Canada; or adjourned date, to testify and give evidence as a witness in this action on the part of the from OWCP should be sent (if applicable, the address of the 17) Agency name and address of reporting office personnel or compensation office). 18) Duty station street address and zip code The address and zip code of the establishment where the Your employee actually works. failure to comply with this d) The injury occurred off the employing agency's premises and the employee was not involved in official "off premise" duties; e) The injury was proximately caused by the employee's willful subpoena is punishable as intent to bring about injury or death to self oryou liable to misconduct, a contempt of court and will make the party on whose behalf maximum penalty of $50 19) Employers Retirement Coverage. this subpoena was issued for a another person, or intoxication; and all damages sustained as a Indicate resultretirement failurethe employee is covered under. which of your system to comply. f) 30) Was injury caused by third party? A third party is an individual or organization (other than the Witness, Honorable injured employee or the Federal government) who is liable for Court in the injury. For instance, the driver ofCounty, causingday of a vehicle an accident in which an employee is injured, the owner of a building where unsafe conditions cause an employee to fall, and a manufacturer whose defective product causes an employee's injury, could all be considered third parties to the injury. 32) Name and address of physician first providing medical care The name and address of the physician who first provided medical care for this injury. If initial care was given by a nurse or other health professional (not a physician) in the employing agency's health unit or clinic, indicate this on a separate sheet of paper. The injury was not reported on Form CA-1 within 30 days following the injury; , one 45 days or more following g) Work stoppage first occurred of the Justices of the the , 20 injury; h) The employee initially reported the injury after his or her employment was terminated; or (Attorney enrolled above and type name below) i) The employee Ismust signin the Civil Air Patrol, Peace Corps, Youth Conservation Corps, Work Study Programs, or other similar groups. Attorney(s) for Employing Agency - Required Codes Box a (Occupation Code), Box b (Type Code), Box c (Source Code), OSHA Site Code The Occupational Safety and Health Administration (OSHA) requires all employing agencies to complete these items when reporting an injury. The proper codes may be found in OSHA Booklet 2014, "Recordkeeping and Reporting Guidelines. Office and OWCP Agency Code P.O. Address This is a four-digit (or four digit plus two letter) code used by OWCP to identify the employing agency. The proper code may be obtained from your personnel or compensation office, or by Telephone No.: contacting OWCP. Facsimile No.: E-Mail Address: Mobile Tel. No.: Form CA-1 Rev. Apr. 1999 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Benefits for Employees under the Federal Employees' Compensation act (FECA) : The FECA, which is administered by the Office of Workers' Compensation Programs (OWCP), provides the following benefits for job-related traumatic injuries: Index No. : : Plaintiff(s) Calendar No. JUDICIAL SUBPOENA (4) Vocational rehabilitation and related services where : directed by OWCP. (1) Continuation of pay for disability resulting from traumatic, -againstjob-related injury, not to exceed 45 calendar days. (To be eligible for continuation of pay, the employee, or someone acting on his/her behalf, must file Form CA-1 within 30 days following the injury and provide medical evidence in support of disability within 10 days of submission of the CA-1. Where the employing agency continue's the employee's pay, the pay must not be interrupted unless one of the provision's outlined in 20 CFR 10.222 apply. : (5) All necessary medical care from qualified medical providers. The injured employee may choose the physician who provides initial medical care. Generally, 25 miles from the place of : injury, place of employment, or employee's home is a reasonable distance to travel for medical care. Defendant(s) : ...................................................... (2) Payment of compensation for wage loss after the expiration of COP, if disability extends beyond such point, or if COP is not payable. If disability continues after COP expires, Form CA-7, with supporting medical evidence, must be filed with OWCP. THE PEOPLE OF THE STATE OF NEW YORK To avoid interruption of income, the form should be filed on the 40th day of the COP period. An employee may use sick or annual leave rather than LWOP while disabled. The employee may repurchase leave used for approved periods. Form CA-7b, available from the personnel office, should be studied BEFORE a decision is made to use leave. For additional information, review the regulations governing the administration of the FECA (Code of Federal Regulations, Chapter 20, Part 10) or pamphlet CA-810. TO (3) Payment of compensation for permanent impairment of certain organs, members, or functions of the body (such as loss or loss of use of an arm or kidney, loss of vision, etc.), or for serious defringement of the head, face, or neck. GREETINGS: Privacy Act WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' the Honorable at the Court Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation located at County ofU.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Programs of the Information which the Office, has the be used to determine eligibility 20 and the amount ofo'clock in the under the FECA, at any recessed benefits payable in room on will day of , for , at noon, and and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the or adjourned date, to testify and give evidence as a witness in this action on the part of 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 health care 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 Your and local agencies for law enforcement purposes, to obtain as a contempt of court and under the you to given to Federal, state failure to comply with this subpoena is punishable information relevant to a decisionwill makeFECA,liable to the whether benefits are being this subpoena was whether prohibited dual payments are being made, all where appropriate, to determineparty on whose behalf paid properly, including issued for a maximum penalty of $50 and and, damages sustained as a pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) result of your failure to comply. 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 Witness, Honorable , one of the Justices of the of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. Court in County, day of , 20 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. (Attorney must sign above and type name below) Receipt of Notice of Injury This acknowledges receipt of Notice of Injury sustained by (Name of injured employee) Attorney(s) for Which occurred on (Mo., Day, Yr.) At (Location) Office and P.O. Address Signature of Official Superior *U.S. GPO: 1999-454-845/12704 Title Date (Mo., Day, Yr.) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form CA-1 Rev. Apr. 1999 American LegalNet, Inc. www.USCourtForms.com ,