What is Form CA-17?
Form CA-17, also known as the Duty Status Report, is an essential document used to communicate an employee's work status following an injury. This form plays a crucial role in determining whether the employee is fit to return to work and outlines any necessary work restrictions. It consists of two sections: Side A is filled out by the supervisor, while Side B is completed by the treating physician. By providing vital information about the injury, work duties, and medical condition, it helps employers and the Office of Workers' Compensation Programs (OWCP) manage workers' compensation claims effectively.
What is Form CA-17 used for?
Form CA-17 is essential for documenting workplace injuries. Here’s what it covers:
- Reporting Injury Details: Documents how the injury happened and which body parts are affected.
- Work Status Update: Provides information about the employee's work ability and return-to-work status.
- Compensation Eligibility: Assesses eligibility and benefits under the Federal Employees' Compensation Act.
- Medical Certification: Gathers the treating physician’s report, including findings and diagnoses.
- Workplace Safety: Evaluates the injury's effect on job duties and identifies safety improvements needed.
How to fill out Form CA-17?
- 1
Fill in the employee's name, Social Security number, date of injury, occupation, and work hours on Side A.
- 2
Describe how the injury occurred and the affected body parts.
- 3
Specify usual work requirements, including weight carried.
- 4
Provide clinical findings and diagnosis in the Physician's Section.
- 5
State if the medical history aligns with the supervisor's information.
- 6
Indicate if the employee can return to work.
- 7
Verify all fields are complete, then download the form for submission.
Who is required to fill out Form CA-17?
Form CA-17 is completed by two key groups: the employee's supervisor and the treating physician. The supervisor provides essential details on work duties and injury specifics, while the physician documents clinical findings and work restrictions.
After completion, the Office of Workers' Compensation Programs (OWCP) uses the form to assess workers' compensation claims, determining eligibility and benefit amounts, and it is also sent to the employing agency for documentation and return-to-work processes.
When is Form CA-17 not required?
Form CA-17 isn't required if the employee's injury or disease isn't job-related or if they decline medical care. Additionally, it doesn't apply to occupational diseases or injuries that happened more than 48 hours ago, as proving work-relatedness becomes difficult after that timeframe.
When is Form CA-17 due?
The deadline for Form CA-17 is within 2 days after the physician completes it. It’s important to return this form promptly to the Office of Workers' Compensation Programs (OWCP) to prevent any delays or penalties in processing your workers' compensation claims. Make sure all information is accurate to ensure a smooth process.
How to get a blank Form CA-17?
To get a blank Form CA-17, Duty Status Report, simply visit our website. The Office of Workers' Compensation Programs (OWCP) issues this form, and we have it pre-loaded for you to fill out. Remember, our platform aids in filling and downloading forms, but not filing them.
How to sign Form CA-17 online?
To sign Form CA-17 online, use PDF Guru to create a simple electronic signature. Ensure your signature complies with eSignature laws like ESIGN and UETA for it to be legally valid. Alternatively, you can also add a handwritten signature if it meets the necessary requirements. After filling out the form, download it for your records, but remember, PDF Guru does not support submission. Always check for the latest updates to ensure compliance.
Where to file Form CA-17?
To submit Form CA-17, Duty Status Report, send the completed form by mail to the Office of Workers' Compensation Programs (OWCP).
Don't forget to include a copy for your employing agency. Both addresses are provided on the form for your convenience.
