Attachment 7 DLA inj.docx

JOB INJURY REPORT PACKAGE

DLA ORGANIZATIONS

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. The attached Form CA-1 must be completed for all injuries, no matter how minor the injury may seem. Fill in items 1 through 16 within two (2) workdays and give it to your supervisor. If you have any questions about your injury or what benefits you are entitled to, please call the DLA, ICC Unit @ Toll Free 1-866-737-9724.

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. Fax an advanced copy of the Form CA-1 to: DSN: 427-7128 or 8348 COMM: (703) 767 7128 or 8348; then send the original to: DEFENSE LOGISTICS AGENCY J1; INJURY COMPENSATION CENTER; 8725 John J. Kingman Rd, Stop 6231; Ft. Belvoir, VA 22060-6221 within two (2) workdays after receipt of the form from the employee. If you have any questions about this report, please call the DLA, ICC Unit @ Toll Free 1-866-737-9724.

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 the Environmental, Safety and Occupational Health Office (DES-CE), phone, (614) 692-3964, ext. 2-3964, or DSN 850-3964 immediately. The DLA Form 1591 must be completed and forwarded to DES-CE within two (2) workdays from the date of the mishap. The Environmental, Safety and Occupational Health Office Staff will assist you in properly completing the DLA Form 1591 and answer any questions you may have concerning your reporting responsibilities.

NOTE TO EMPLOYEES & SUPERVISORS: More detailed information on the compensation program requirements can be found at: http://www.hr.dla.mil/hroc/bnfts/owcp/owcp.htm

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.

ATTACHMENT 7