Official Superiors Report Of Employees Death
Official Superiors Report Of Employees Death Form. This is a Official Federal Forms form and can be use in US Dept Of Labor.
Tags: Official Superiors Report Of Employees Death, CA-6, Official Federal Forms US Dept Of Labor,
Official Superior’s Report of Employee’s Death I U.S. Department of Labor Employment Standards Administration Office of Workers’ Compensation Programs 1. Name of Deceased Employee (Last, first. middle) 3. 2. Date of Birth (MO ., day, year) * * / 4. Social Security N O , 0 Male 0 Female 5. Department or Agency 6. OWCP Agency Code 8. Name and Address of Reporting Office 9. Name and Office Phone Number of Employee’s Official Superior 7. OSHA Site Code I 11. Date and Hour of Death (MO ., day, year) 10. Date and Hour of Injury (MO ., day, year) 0 AM 12. Date and Hour Employee’s Pay Stopped (MO ., day, year) c] AM 0 AM cl PM 0 PM 13. Describe how injury occurred 0 PM 14. Was employee in perfo rmance of duty when injury occurred? 0 Yes 0 No (if No, explain) 17. lmmediate cause of death (Attach medical 16. Location where death occurred 15. Location where Injury occurred : and autopsy report if available) 18. Employee’s pay rate as of b. Subsistence a. Base pay c. Quarters d. Other A. Date of injury $ per $ per S per $ per B. Date pay stopped $ per S per S per S per 19. Did employee work in positron held at tim of injury for a full eleven months immediately prior to the injury? 0 yes 0 20. If answer to 19 is no, would position have afforded employment for eleven months except for the injury? No 0 Yes ci No 22. a. Occupation code 21. Did employee receive leave pay for any part of period from time pay stopped to date of death? (Give inclusive dates) b. Type code OWCP use - NOI code 23. Did employee receive continuation of pay (COP) during perrod pnor to death? a. Pay rate used for COP $ c. Source code To From per i 24. If employee was enrolled in Health b. Inclusive dates of cop From Benefit Plan for self and family, show HBS Code Number: To I 25. Show date through which HBS deductions were last made (MO ., day, year) 26. ldentify employee’s Federal Retirement Plan: 0 CSBS 0 F E R S 0 O t h e r 28. If injury was caused by a third party, give name and address of third party 27. If employee received medical care prior to death, give name and address of attending physician 29. Give name and address of the attorney representing the survivors if legal action is instituted against the third party / I $ I 31. If employee was a member of the Armed Services the United States, show: 1 32. Has claim for survivor’s benefits been filed with the Office of Personnel Management? Branch of Service: 0 Serial No. (If known) Yes 0 No 33. Name and address of employee’s spouse or next of kin (Show relationship, if other than spouse) 34. Signature of Official Superior 35. Title / 36. Date (MO ., day, year) Form CA-6 Rev. Jan. 1997 2000 © American LegalNet, Inc. Instructions for Completing Form CA-6 When a Federal employee dies as a result of injury in performance of duty or because of an employment related disease, the death should be reported on this form. This form eliminates the need to complete and file the official superior’s report on Form CA-l, Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation or Form CA-2, Federal Employee’s Notice of Occupational Disease and Claim for Compensation. The form is to be completed by the deceased employee’s official superior or other authorized official of the employing agency. It should be accompanied by a certified copy of the death certificate. when submitted to OWCP. Form CA-5 or CA-5b should be supplied to the employee’s spouse or next of kin. If additional space is required, attach separate sheets and number the answers to correspond with the items on the form. For additional information about death benefits, see 20 CFR 1.1 and/or Chapter 810, Injury Compensation, Federal Personnel Manual. Box 22a (Occupation Code), Box 22b (Type Code), Box 22c (Source Code), OSHA She 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. OWCP Agency Code 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 contacting OWCP. 2000 © American LegalNet, Inc.