Attachment 6 DFAS inj.docm

JOB INJURY REPORT PACKAGE

DFAS-CO AND SERVICED ACTIVITIES

Attached are accident, compensation, and medical officer report forms that should be completed as indicated.

EMPLOYEE’S INSTRUCTIONS

DSCC Form 1157: Complete the top half of the attached DSCC Form 1157. Return the package to the attending medical authority, who will complete the bottom half of the form and provide treatment.

Form CA-20: You are responsible for providing the treating physician with the Form CA-20. This form is used to obtain the necessary medical evidence to support the alleged injury/illness.

Form CA-1: You are responsible for initiating the Form CA-1. This form should be completed for all injuries, no matter how minor the injury may seem. Fill in items 1 through 16 within two (2) working days and give it to your supervisor. Please call DFAS-PSO-IQRB, (317) 510-4451/ 5021/ 6377 or DSN 699-4451/ 5021/ 6377 for authorization of COP and for information regarding your entitlement to benefits.

SUPERVISOR’S INSTRUCTIONS

Form CA-1: The Supervisor or official superior is required to complete the reverse side (Items 17 through 38, as appropriate) of the Form CA-1. Return it to: “Defense Finance & Accounting Service, Regional Support Center, ATTN: DFAS-PSO-IQRB, 8899 E. 56th St., Indianapolis, IN 46249-6494 within two 2 working days after receipt of the form from the employee. If you have any questions about this report, please call DFAS-PSO-IQRB, (317) 510-4451/ 5021/ 6377 or DSN 699-4451/ 5021/ 6377.

DLA FORM 1591: THE SUPERVISOR IS REQUIRED TO COMPLETE A DLA FORM 1591, MISHAP REPORT FOR ALL MISHAPS. If your employee has been injured, contact Kara Mettille, DFAS-RSABP/CO (Safety and Health, Administrative Services Directorate) at 614 693-8076 immediately. The DLA Form 1591 must be completed and forwarded to DFAS-RSABP/CO within five (5) working days from the date of the mishap. The Safety and Health staff will assist you in properly completing the DLA Form 1591 and answer any questions you may have concerning your reporting responsibilities.

REMINDER TO MEDICAL OFFICER: Please remove the top 3 copies, for appropriate distribution of the DSCC Form 1157 and return the rest of the package to the employee for proper completion of the remaining forms.

NOTE TO EMPLOYEES & SUPERVISORS: More detailed information on the compensation program requirements can be found at:

https://eportal.dfas.mil/content/Corporate%20Resources/Human%20Resources/Benefits/workcomp.pdf

ATTACHMENT 6