Who Files Form CA-1?
Form CA-1 is called the Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. This form must be completed by federal employee, witness and employing agency. There are special parts to fill in for every of the above-mentioned parties.
What is Form CA-1 for?
This form is specially designed to report the traumatic injury and decide on the amount of compensation that must be paid to you by the employer. The main purpose of this document is to declare that a traumatic injury was sustained or is alleged to be sustained. It is a legal notice to the supervisor of the employee. You may complete the document after medical care was provided.
When is Form CA-1 Due?
You must file Form CA-1 not later than after two days the injury took place. Try to prepare this form in time to receive the work injury compensation.
Is Form CA-1 Accompanied by Other Forms?
You must file this form only. Your supervisor must complete Form 1769 that is called the Accident Report and provide witnesses’ statements.
What Information do I Include in Form CA-1?
The form is divided into three sections. The first one must be completed by the employee with the injury. It is required to indicate the following information:
- Name;
- Social security number;
- Date of birth;
- Sex;
- Home telephone;
- Grade as of date of injury (level and step);
- Mailing address;
- Dependents (children, spouse, others);
- Description of the injury (place, date, time, date of the form completion, applicant’s occupation, injury cause and nature);
- Signature.
The next part must be filled by the witness. It includes the state of witness, the name and address of the witness, date and signature. The last part is the supervisor’s report.
Where do I Send Form CA-1?
You must send this document to the U.S. Department of Labor, Office of Workers’ Compensation Programs.
