Fill in a Valid Ca 1 Template

The CA-1 form is a document required by the U.S. Department of Labor for federal employees to report a traumatic injury and claim for compensation or continuation of pay. When an employee experiences a job-related injury, this form must be completed accurately and submitted promptly to secure necessary benefits. If you're looking to fill out the CA-1 form, click the button below to get started.

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The Ca 1 form, officially known as the Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay and Compensation, serves a critical purpose for federal employees who sustain job-related injuries. This form is designed to collect essential information about the employee, the nature of the injury, and the circumstances surrounding it. Employees must complete the first 15 sections, documenting their personal details, including contact information and the specifics of the injury sustained during their work duties. Witnesses can contribute by filling out the designated section at the bottom, providing additional perspective on the incident. The form also requires the employing agency, typically the supervisor or a compensation specialist, to fill out shaded areas, which ensure a comprehensive overview of the situation, including the agency's details and the employee’s regular work hours. By submitting the Ca 1 form promptly, employees can claim medical treatment and seek continuation of pay for up to 45 days while awaiting a decision on their claim. The implications of this form extend beyond injury recovery; the information provided can influence benefit eligibility under the Federal Employees’ Compensation Act (FECA), emphasizing the importance of accurate and thorough completion.

Ca 1 Example

U.S. Department of Labor

Office of Workers' Compensation Programs

Federal Employee's Notice of Traumatic Injury and

Claim for Continuation of Pay/Compensation

Employee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.

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)

1a. Email address

2. Social Security Number

3.	Date of birth Mo. Day Yr.	4. Sex		5. Home telephone		6. Grade as of	Level		Step
		Male	Female			date of injury	Level		Step
7.	Employee's home mailing address (include street address, city, state, and ZIP code)							8. Dependents
									Wife, Husband
									Children under 18 years
City					State	ZIP Code			Children under 18 years
									Other

Description of Injury

9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)

10.	Date injury occurred	Time	a.m.	11. Date of this notice	12. Employee's occupation
	Mo. Day Yr.		a.m.	Mo. Day Yr.
	Mo. Day Yr.		p.m.	Mo. Day Yr.
			p.m.

13.	Cause of injury (Describe what happened and why)

14. Nature of injury (identify both the injury and the part of the body, e.g., fracture of left leg)

a. Occupation code

b. Type code

c. Source code

OWCP Use - NOI Code

Employee Signature

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 of regular pay (COP) not to exceed 45 days and compensation for wage loss if disability for work continues beyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick or annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.

b. Sick and/or Annual Leave

I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information
to the U.S. Department of Labor, Office of Worker's Compensation Program (or to its official representative). 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	Date

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.

Have your supervisor complete this 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)

Name of witness	Signature of witness		Date signed

Address	City	State	ZIP Code

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP.

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Form CA-1 Revised October 2018

Official Supervisor's Report: Please complete information requested below:

Supervisor's Report

17. Agency name and address of reporting office (include street address, city, state, and ZIP code)

OWCP Agency Code

OSHA Site Code

City

State

ZIP Code

18.

Employee's duty station (include street address, city, state and ZIP code)

City

State

ZIP Code

19 Employee's retirement coverage

CSRS

FERS

Other, (identify)

20.

Regular

From:

a.m.

To:

a.m.

21. Regular

Sun.

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

work

p.m.

work

hours

schedule

22.

Date of Injury

23. Date notice received

24. Date stopped work

a.m.

Mo. Day Yr.

Time:

p.m.

25.

Date pay stopped

26. Date 45 day period began

27. Date returned to work

a.m.

Mo. Day Yr.

Time:

p.m.

28.

Was employee injured in performance of duty?

Yes

No (If "No," explain)

29.

Was injury caused by employee's willful misconduct, intoxication, or intent to injure self or another?

Yes (If "Yes," explain)

30.

Was injury caused by third party?

31. Name and address of third party (include street address, city, state, and ZIP code)

No (If "No," go

Yes

City

State

ZIP Code

to Item 32,)

32. Name and address of physician first providing medical care (include street address, city, state, ZIP code)

33. First date medical

Mo. Day

Yr.

care received

City

State

ZIP Code

34.Do medical reports

Yes

show employee is

disabled for work?

35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses?

Yes

No (If "No," explain)

36. If the employing agency controverts continuation of pay, state the reason in detail.

37.Pay rate when employee stopped work Per

Signature of Supervisor and Filing Instructions

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 knowledge with the following exception:

Name of supervisor (Type or print)

Signature of supervisor	Date

Supervisor's Title	Office phone

39. Filing instructions	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
	Lost time covered by leave, LWOP, or COP: forward this form to OWCP
	First Aid Injury

			Form CA-1
			Revised October 2018
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Instructions for Completing Form CA-1

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.

Employee (or person acting on the employees' behalf)

1a) Email address

14) Nature of injury

Injured workers should provide an email address when completing this form. Pursuant to policy established by the Department of Labor, Office of Workers' Compensation Programs (OWCP), Division of Federal Employees' Compensation, email communication on case specific inquiries is not allowed due to security concerns. However, obtaining claimant email addresses at the point of filing will allow OWCP to share general, non-case specific information with injured workers earlier in the claims submission process. As a longstanding policy and in an effort to protect the identities and personal information of claimants under the Federal Employees' Compensation Act, and to allow better tracking of incoming communications, we do not use two-way email as a primary method of interaction with claimants and their representatives.)

13) Cause of injury

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?)

Give a complete description of the condition(s) resulting from your injury. Specify the right or left side if applicable (e.g., fractured left leg: cut on right index finger).

15) Election of COP/Leave

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 during the 45 days of COP entitlement.

Supervisor

	As the time the form is received, complete the receipt of notice of	33) First date medical care received
	injury and give it to the employee. In addition to completing	The date of the first visit to the physician listed in Item 31.
	Items 17 through 39, the supervisor is responsible for obtaining
	the witness statement in Item 16 and for filling in the proper codes	36) If the employing agency controverts continuation of
	in shaded boxes a, b, and c on the front of the form. If medical	36) If the employing agency controverts continuation of
	expense or lost time is incurred or expected, the completed form	pay, state the reason in detail.
	should be sent to OWCP within 10 working days after is received.	COP may be controverted (disputed) for any reason; however,
	The supervisor should also submit any other information or	COP may be controverted (disputed) for any reason; however,
	The supervisor should also submit any other information or	the employing agency may refuse to pay COP only if the
	evidence pertinent to the merits of this claim.	controversion is based upon one of the nine reasons given
	If the employing agency controverts COP, the employee should	below:
	be notified and the reason for controversion explained to him or	a) The disability was not caused by a traumatic injury.
	her.	a) The disability was not caused by a traumatic injury.
	her.
	17) Agency name and address of reporting office	b) The employee is a volunteer working without pay or for
	17) Agency name and address of reporting office	nominal pay, or a member of the office staff of a former
		nominal pay, or a member of the office staff of a former
	The name and address of the office to which correspondence	President;
	from OWCP should be sent (if applicable, the address of the	c) The employee is not a citizen or a resident of the United
	personnel or compensation office).
	18) Duty station street address and zip code	States or Canada;
	18) Duty station street address and zip code	d) The injury occurred off the employing agency's premises and

	The address and zip code of the establishment where the	the employee was not involved in official "off premise" duties;
	employee actually works.	e) The injury was proximately caused by the employee's willful

	19) Employers Retirement Coverage.	misconduct, intent to bring about injury or death to self or
	19) Employers Retirement Coverage.	another person, or intoxication;
	Indicate which retirement system the employee is covered under.	f) The injury was not reported on Form CA-1 within 30 days
		f) The injury was not reported on Form CA-1 within 30 days
	30) Was injury caused by third party?	following the injury;
	30) Was injury caused by third party?
	A third party is an individual or organization (other than the	g) Work stoppage first occurred 45 days or more following
		the injury;
	injured employee or the Federal government) who is liable for	the injury;
	the injury. For instance, the driver of a vehicle causing an	h) The employee initially reported the injury after his or her
	accident in which an employee is injured, the owner of a
	accident in which an employee is injured, the owner of a	employment was terminated; or
	building where unsafe conditions cause an employee to fall, and	employment was terminated; or
	a manufacturer whose defective product causes an employee's	i) The employee is enrolled in the Civil Air Patrol, Peace Corps,
	injury, could all be considered third parties to the injury.
		Youth Conservation Corps, Work Study Programs, or other
		Youth Conservation Corps, Work Study Programs, or other
	32) Name and address of physician first providing medical	similar groups.
	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.

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Form CA-1

Revised October 2018

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Instructions for Completing Form CA-1 Continued

Employing Agency - Required Codes

Box a (Occupation Code), Box b (Type Code),OWCP Agency 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."

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.

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:

(1) Continuation of pay for disability resulting from traumatic, job-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.

(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. To avoid interruption of income, the form should be filed on the 40th day of the COP period.

(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.

(4)Vocational rehabilitation and related services where directed by OWCP.

(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.

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.

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby 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 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 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 disclosure 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.

Receipt of Notice of Injury

This acknowledges receipt of Notice of Injury sustained by (Name of injured employee)

Which occurred on (Mo. Day, Yr.)

At (Location)

Signature of Official Superior

Title

Date (Mo. Day, Yr.)

*U.S. GPO: 1999-454-845/12704

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Form CA-1

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File Breakdown

Fact Name	Description
Purpose of Form	The CA-1 form is used by federal employees to report traumatic injuries and claim continuation of pay and compensation. It ensures that necessary information is provided for the processing of claims.
Completion Requirements	Sections 1 to 15 of the form must be filled out by the employee, while the employing agency completes the shaded boxes for their section. The witness statement must also be provided if applicable.
Legal Framework	This form operates under the Federal Employees' Compensation Act (FECA), which governs compensation for federal employees suffering work-related injuries.
Submission Timeline	The form must be filed within 30 days of the injury. Delays in submission may impact eligibility for benefits, including continuation of pay.

Guide to Using Ca 1

Completing the CA-1 form is an essential step in documenting a traumatic injury sustained while on duty. After you fill out this form, it will be submitted to the relevant authorities to initiate the claims process. Here are the steps you will need to follow when filling out the form:

Employee Information: Start by entering your name in boxes 1–3. This includes your last name, first name, and middle name, along with your email address and social security number.
Date of Birth: Fill in your date of birth in box 3.
Sex: Indicate your sex in box 4 by checking the appropriate box (Male or Female).
Contact Information: Enter your home telephone number in box 5 and your residential mailing address in box 7, which should include your street address, city, state, and ZIP code.
Dependents: Complete box 8 to list any dependents, specifying if you're including a spouse or children under 18 years of age.
Injury Details: Describe where the injury occurred in box 9 and provide the date and time the injury took place in boxes 10 and 11.
Occupation: Fill in your occupation in box 12.
Cause and Nature of Injury: In boxes 13 and 14, describe how the injury happened and specify the type of injury as well as the body part affected.
Certification: In box 15, read the certification statement and sign and date it to confirm the information provided is accurate.
Witness Section: If applicable, have a witness fill out the bottom section (box 16) by providing a detailed statement regarding what they observed, along with their name, signature, date signed, and address.
Supervisor Section: The supervisor should complete the shaded boxes [a, b, and c] as well as boxes 17-39, which include specific details about the agency, employee's duty station, and additional information relating to the injury.

Ensure that you thoroughly review the completed form for accuracy before submission. If you have any additional documentation to support your claim, attach it to the form as necessary. Once all sections are filled out completely and accurately, the CA-1 form should be submitted to the appropriate contact at your agency or filed according to your agency's procedures.

Get Answers on Ca 1

What is the purpose of Form CA-1?

Form CA-1, officially known as the “Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation,” is a form used by U.S. federal employees to report traumatic injuries sustained while on duty. The purpose of this form is twofold: it serves as a notification to the employer about the injury and initiates a claim for certain benefits. These benefits may include Continuation of Pay (COP) for up to 45 days, compensation for wage loss if the disability continues beyond this period, and coverage for necessary medical care related to the injury.

How should an employee complete Form CA-1?

To complete Form CA-1, the employee must fill out all relevant sections, specifically boxes 1 through 15. Necessary details include the employee’s name, contact information, a description of the injury, and acknowledgment that the injury occurred while performing job duties. It’s essential to provide specific information regarding the nature and cause of the injury. The employee should avoid filling out any shaded areas. Additionally, if a witness was present during the incident, their information must be included in section 16. Finally, the employee must sign and date the form, certifying the accuracy of the information provided.

What happens after Form CA-1 is submitted?

Once Form CA-1 is submitted, the employing agency must assess the claim. There are specific timelines the agency must adhere to, such as acknowledging receipt of the notice within a certain period. If the agency accepts the claim, it will facilitate the payment of Continuation of Pay for the eligible period. If any disputes arise regarding the claim, the employee will be informed along with the reasons for the dispute. In cases where continuation of pay is not granted, other benefits may still be available if eligibility criteria are met. The supervisor’s completed report also plays a crucial role in processing the claim.

What should an employee do if their claim is denied?

If an employee’s claim under Form CA-1 is denied, it’s important to understand the reasons behind the denial. The employee should receive a written explanation from the employing agency. They may have the option to appeal the decision or request a review of the claim. In the meantime, if the claim is denied, the employee may need to rely on sick leave or annual leave while recovering from the injury. For further assistance, reaching out to the Office of Workers' Compensation Programs (OWCP) can provide additional guidance on next steps.

Common mistakes

Filling out the CA-1 form can be a straightforward process, yet many employees make errors that can complicate their claims. The following are ten common mistakes that may occur when completing this important document.

One frequent error is not providing complete and accurate information in boxes 1 through 15. Employees sometimes skip sections or provide incomplete data, such as not including their full name or social security number. Each of these details is critical. Missing or incorrect information can lead to delays in processing or even denial of the claim.

Another error involves the date of injury. Failing to accurately specify the date can cause significant problems. If an employee does not record the date promptly or mistakenly enters an incorrect date, this could affect eligibility for benefits under the law.

People also often overlook box 15 where they must certify the truthfulness of their statement. Neglecting to sign this section can render the form invalid. The certification reaffirmation must be complete to avoid complications in the claims process.

Additionally, the description of the injury is frequently insufficient. When asked to detail the cause of the injury, employees may provide vague or generic descriptions. A detailed account of the incident is essential for the claim process. Include specifics such as how the injury occurred, the exact location, and the exact body parts affected.

Providing an email address in box 1a is often missed. While not mandatory, it can facilitate communication with the Office of Workers' Compensation Programs (OWCP). Failure to include this information may hinder timely updates or responses to inquiries about the claim.

Submitting the CA-1 form too late presents yet another challenge. Claims must be filed within 30 days of the injury. Some employees delay reporting their injuries, which can lead to loss of benefits. It is crucial to submit the form promptly to ensure coverage.

Many claimants also neglect to coordinate with their witnesses. Completing the witness statement is sometimes seen as “optional,” but it is an integral part of the claim. Not doing so can result in insufficient corroboration of the injury details.

In addition, employees often fail to maintain copies of their completed forms. Keeping a copy of the CA-1 for personal records is crucial in case questions arise later on. Without this documentation, employees may struggle to provide proof of their claims or submissions.

Obscuring information is another common issue. When filling out the CA-1 form, some individuals use whiteout or attempt to cover mistakes in ways that can make text unreadable. Clarity is paramount, and striking through incorrect information and writing a correction is advised.

Finally, some employees miss essential details required by the supervisor at the bottom of the form. Properly completing the sections designated for supervisors is just as important as filling out the employee sections. Lack of commitment in this area can lead to unprocessed claims.

Understanding these ten common mistakes can help ensure that filling out the CA-1 form is done correctly and thoroughly, minimizing delays and complications in processing workers' compensation claims.

Documents used along the form

When filing a claim related to a work-related injury under the Federal Employees' Compensation Act (FECA), it's essential to understand the various forms and documents that often accompany the CA 1 form. Each of these documents serves a specific purpose in helping to process and support the claim effectively. Below is a list of some key forms that are frequently used in conjunction with CA 1.

Form CA-2: This form is utilized to report a work-related injury that occurs over time rather than from a specific incident. Employees use this form to detail the gradual nature of their injury, such as repetitive strain or long-term exposure to hazardous conditions.
Form CA-7: If an employee’s disability extends beyond the initial 45 days covered by the CA 1 form, Form CA-7 is necessary for claiming wage loss compensation. This form requires reporting the duration of disability and any supporting medical evidence.
Form CA-7b: This form is specifically designed for employees to indicate their intention to use sick or annual leave instead of continuing pay. It may accompany the CA-7 when the employee chooses to use leave during their recovery.
Form CA-16: Often requested by the supervisor, Form CA-16 provides authorization for medical treatment. It allows employees to see a physician designated by the employer without needing to pay upfront, helping them receive necessary care promptly.
Form OWCP-1500: Used primarily for billing purposes, this form is submitted by healthcare providers seeking reimbursement for medical services rendered to the injured employee. It details the nature of the treatment and associated costs.
Documentation of Witness Statements: Statements made by witnesses at the time of the incident can be vital for substantiating the claim. These statements clarify the circumstances surrounding the injury and help establish its legitimacy.

In summary, understanding the role and requirements of these forms is crucial for a smooth claims process under the FECA. Properly completing and submitting the relevant documents ensures that employees receive the benefits and support they need during their recovery from work-related injuries.

Similar forms

The CA-1 form shares similarities with several other forms and documents related to worker’s compensation claims. Here are four of those documents, along with a brief explanation of how they are alike:

Form CA-2: Notice of Occupational Disease - Like the CA-1, the CA-2 form is used to report an injury or illness. However, while the CA-1 is specifically for traumatic injuries, the CA-2 is designed for occupational diseases that develop over time.
Form CA-7: Claim for Compensation - This form is used to apply for compensation due to wage loss after the continuation of pay (COP) period has ended. Similar to the CA-1, the CA-7 requires detailed information about the injury and its impact on work.
Form CA-7a: Additional Information for a Claim for Compensation - Like the CA-1, this document supports a claim for compensation and provides additional details needed to assess the claim. It collects crucial information about medical treatment and lost wages.
Form CA-16: Authorization for Examination and/or Treatment - Both forms involve medical information and treatment requirements. The CA-16 provides authorization for medical care needed after an injury, while the CA-1 documents the injury itself and the request for continuation of pay.

Dos and Don'ts

When filling out the CA-1 form, it’s essential to follow certain guidelines to ensure your information is complete and accurate. Here are four things you should and shouldn't do when completing the form:

Do: Complete all boxes 1 - 15 as instructed.
Do: Provide a detailed description of the cause and nature of your injury.
Do: Sign and date the form to certify the information is true.
Do: Include your email address for further communication, if applicable.

Don't: Leave any shaded areas blank, as they are designated for your supervisor or compensation specialist.
Don't: Provide incomplete or vague descriptions of the injury; clarity is crucial.
Don't: Forget to attach any necessary supplemental statements if more space is needed.
Don't: Delay filing the form; do so within 30 days of the injury to ensure your claim is processed.

Misconceptions

Misconception 1: The CA-1 form is optional for employees.

The CA-1 form is mandatory. Employees must complete and submit this form within 30 days of the injury to claim benefits.

Misconception 2: You don't need to provide an email address on the form.

While the email address is requested, it is used only for general communication about the case, not for case-specific matters.

Misconception 3: Only the injured employee can complete the entire form.

Supervisors and compensation specialists also have specific parts of the form that they must complete to ensure compliance.

Misconception 4: You can complete shaded areas on the form.

Employees must leave shaded areas blank, as these are designated for the supervisor's completion.

Misconception 5: The form can be submitted at any time after a workplace injury.

The CA-1 form must be submitted within 30 days of the injury to ensure eligibility for benefits.

Misconception 6: You can select any type of leave during the first 45 days of your injury.

If COP is granted, it does not charge against sick or annual leave. If sick or annual leave is chosen, COP cannot be claimed afterward for that period.

Misconception 7: Medical evidence is not necessary when filing the CA-1 form.

Medical evidence must support the claim and should follow the submission of the CA-1 within ten days.

Misconception 8: You can receive continuation of pay (COP) without filing the form.

To be eligible for COP, the CA-1 form needs to be filed correctly and on time, within 30 days of the injury.

Misconception 9: If the claim is denied, you lose all rights to benefits.

You may still explore options for appeal or file a different claim with appropriate documentation if the initial claim is denied.

Key takeaways

The CA-1 form is essential for federal employees who experience a traumatic injury while on the job. Proper completion is necessary to claim benefits under the Federal Employees' Compensation Act.
Employees must fill out all boxes from 1 to 15, ensuring all information is accurate. Any errors could delay the processing of the claim.
The shaded areas of the form should not be completed by the employee. Instead, those sections are designated for the supervisor or compensation specialist.
When detailing the cause of the injury, specificity is crucial. A thorough description helps clarify the circumstances and can significantly impact the claim's outcome.
Employees have a 30-day window from the date of injury to submit the CA-1 form to be eligible for continuation of pay (COP) and compensation.
If the claim is accepted, employees are entitled to up to 45 calendar days of COP, which does not affect sick or annual leave balances.
After the initial 45 days, employees must file a CA-7 form if disability extends beyond this period to claim compensation for wage loss.