CA-17.pdf

U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs

Duty Status Report

This form is provided for the purpose of obtaining a duty status report for the employee named below. This request does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any previous authorization issued in this case. This request for information is authorized by law (5 USC 8101 et seq.) and is required to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974 and the OMB Cir. A-108. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

SIDE B - Physician: Complete this sideSIDE A - Supervisor: Complete this side and refer to physician

1. Employee's Name (Last, first, middle)

3. Social Security No.2. Date of Injury (Month, day, yr.)

11. Other Disabling Conditions10. Diagnosis Due to Injury

i. Pulling/Pushing

n. Operating Machinery

o. Temp. Extremes dBA dBAs. Noise (Give dBA) Hrs Per Day Hrs Per Day

14. Are Interpersonal Relations Affected Because of a Neuropsychiatric

Condition? (e.g. Ability to Give or Take Supervision, Meet Deadlines,t. Other (Describe) etc.) Yes No (Describe)

Form CA-17 Rev. Jan. 1997

e. Climbing

(Specify) range in degrees F

OMB No. 1215-0103 Expires: 10-31-08

OWCP File Number (If known)

8. Does the History of Injury Given to You by the Employee Correspond to that Shown in Item 5? No (If not, describe)Yes

9. Description of Clinical Findings

4. Occupation

5. Describe How the Injury Occurred and State Parts of the Body Affected

6. The Employee Works Hours Per Day Days Per Week

7. Specify the Usual Work Requirements of the Employee. Check Whether Employee Performs These Tasks or is Exposed Continuously or intermittently, and Give Number of Hours.

12. Employee Advised to Resume Work?

Yes, Date Advised No/ /

13. Employee Able to Perform Regular Work Described on Side A?

Part-TimeFull-Time orYes, If so Hrs Per Day

No, If not, complete below:

Activity Continuous Intermittent Continuous Intermittent

a. Lifting/Carrying:

State Max Wt.

#Ibs. #Ibs.

Hrs Per Day

#lbs. #Ibs.

Hrs Per Day

b. Sitting Hrs Per Day Hrs Per Day

c. Standing Hrs Per Day Hrs Per Day

d. Walking Hrs Per Day Hrs Per Day

Hrs Per Day Hrs Per Day

f. Kneeling Hrs Per Day Hrs Per Day

g. Bending/Stooping Hrs Per Day Hrs Per Day

h. Twisting Hrs Per Day Hrs Per Day

Hrs Per Day Hrs Per Day

j. Simple Grasping Hrs Per Day Hrs Per Day

k. Fine Manipulation

(includes keyboarding) Hrs Per Day Hrs Per Day

l. Reaching above

Shoulder Hrs Per Day Hrs Per Day

m. Driving a Vehicle (Specify) Hrs Per Day Hrs Per Day

Hrs Per Day Hrs Per Day range in degrees F

p. High Humidity Hrs Per Day Hrs Per Day

q. Chemicals, Solvents, etc. (Identify) Hrs Per Day Hrs Per Day

r. Fumes/Dust (identify) Hrs Per Day Hrs Per Day

15. Date of Examination 16. Date of Next Appointment

17. Specialty 18. Tax Identification Number

19. Physician's Signature 20. Date

INSTRUCTIONS FOR COMPLETING DUTY STATUS REPORT (CA-17)

Complete Side A and refer the form to the physician to complete Side B.

Fill in the address of the Employing Agency and the appropriate OWCP District Office in the spaces below. Enter the OWCP file number in the top right corner.

SUPERVISOR:

Complete Side B, sign and return to the employing agency within 2 days to prevent interruption of the employee's income. Fill in your name and address.

PHYSICIAN:

Medical Facility Name and Address

Send Original Report to:

Employing Agency Address

Send a Copy of This Report to:

OFFICE OF WORKERS' COMPENSATION PROGRAMS

CERTIFICATION: BY SIGNING BLOCK 19 ON THE FRONT OF THIS FORM, THE PHYSICIAN

CERTIFIES AS FOLLOWS:

I CERTIFY THAT ALL THE STATEMENTS IN RESPONSE TO THE

QUESTIONS ASKED ON THIS FORM CA-17 ARE TRUE, COMPLETE AND

CORRECT TO THE BEST OF MY KNOWLEDGE. FURTHER, I UNDERSTAND

THAT ANY KNOWINGLY FALSE OR MISLEADING STATEMENT, OR

MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACT, MAY

SUBJECT ME TO FELONY CRIMINAL PROSECUTION.

I FURTHER UNDERSTAND THAT THIS REQUEST DOES NOT CONSTITUTE

AUTHORIZATION FOR PAYMENT OF MEDICAL EXPENSES BY THE

DEPARTMENT OF LABOR, NOR DOES IT INVALIDATE ANY PREVIOUS

AUTHORIZATION ISSUED IN THIS CASE.

Public Burden Statement We estimate that it will take an average of 5 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the OWCP, U.S. Department of Labor, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402

188-0992000G. P. 0. - -

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