Ca 1 Form PDF Details

Californians are required to complete a Ca 1 form when they file their state income taxes. This form is used to report all of your income, including any income that was not reported on your federal tax return. The Ca 1 form is also used to report any deductions or credits that you may be eligible for. Be sure to submit your completed Ca 1 form by the deadline in order to avoid penalties.

You will discover additional information concerning the ca 1 form by looking through the table we put together.

QuestionAnswer
Form NameCa 1 Form
Form Length4 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out1 min 12 sec
Other namesca 1 form workers compensation, ca 1 form department labor, employee s injury, pay compensation workers

Form Preview Example

U.S. Department of Labor

Office of Workers' Compensation Programs

Federal Employee's Notice of Traumatic Injury and

Claim for Continuation of Pay/Compensation

Employee: Please complete all boxes 1 - 15 below. Do not complete shaded areas.

Witness: Complete bottom section 16.

Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.

Employee Data

1. Name of employee (Last, First, Middle)

1a. Email address

2. Social Security Number

3.

Date of birth Mo. Day Yr.

4. Sex

 

5. Home telephone

 

6. Grade as of

Level

Step

 

 

Male

Female

 

 

date of injury

7.

Employee's home mailing address (include street address, city, state, and ZIP code)

 

 

 

8. Dependents

 

 

 

 

 

 

 

 

 

Wife, Husband

 

 

 

 

 

 

 

 

Children under 18 years

City

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

Description of Injury

 

 

 

 

 

 

 

 

9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)

10.

Date injury occurred

Time

a.m.

11. Date of this notice

12. Employee's occupation

 

Mo. Day Yr.

 

Mo. Day Yr.

 

 

 

p.m.

 

 

 

 

 

 

 

 

 

 

 

13.

Cause of injury (Describe what happened and why)

 

14. Nature of injury (identify both the injury and the part of the body, e.g., fracture of left leg)

a. Occupation code

b. Type code

c. Source code

OWCP Use - NOI Code

Employee Signature

15.I certify, under penalty of law, that the injury described above was sustained in performance of duty as an employee of the United States Government and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication. I hereby claim medical treatment, if needed, and the following, as checked below, while disabled for work:

a. Continuation of regular pay (COP) not to exceed 45 days and compensation for wage loss if disability for work continues beyond 45 days. If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick or annual leave, or be deemed an overpayment within the meaning of 5 USC 5584.

b. Sick and/or Annual Leave

I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information

to the U.S. Department of Labor, Office of Worker's Compensation Program (or to its official representative). This authorization also permits any

official representative of the Office to examine and to copy any records concerning me.

 

Signature of employee or person acting on his/her behalf

Date

Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.

Have your supervisor complete this receipt attached to this form and return it to you for your records.

Witness Statement

16. Statement of witness (Describe what you saw, heard, or know about this injury)

Name of witness

Signature of witness

 

Date signed

 

 

 

 

Address

City

State

ZIP Code

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP.

Print Form

Save Form

Reset Form

Form CA-1 Revised October 2018

Official Supervisor's Report: Please complete information requested below:

Supervisor's Report

17. Agency name and address of reporting office (include street address, city, state, and ZIP code)

OWCP Agency Code

OSHA Site Code

City

 

 

 

 

 

 

 

 

 

 

 

State

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

Employee's duty station (include street address, city, state and ZIP code)

 

City

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19 Employee's retirement coverage

 

CSRS

FERS

 

Other, (identify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Regular

From:

a.m.

 

To:

a.m.

21. Regular

 

Sun.

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

 

work

p.m.

 

p.m.

 

work

 

 

hours

 

 

 

 

schedule

 

 

 

 

 

 

 

 

 

 

22.

Date of Injury

 

23. Date notice received

 

 

 

24. Date stopped work

 

 

 

 

 

a.m.

 

 

Mo. Day Yr.

 

 

Mo. Day Yr.

 

 

 

 

 

 

Mo. Day Yr.

 

 

Time:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

Date pay stopped

26. Date 45 day period began

 

27. Date returned to work

 

 

 

 

a.m.

 

 

Mo. Day Yr.

 

 

Mo. Day Yr.

 

 

 

 

 

 

Mo. Day Yr.

 

 

Time:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28.

Was employee injured in performance of duty?

 

Yes

 

No (If "No," explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Was injury caused by employee's willful misconduct, intoxication, or intent to injure self or another?

 

Yes (If "Yes," explain)

No

 

 

 

 

 

 

 

 

 

 

 

 

30.

Was injury caused by third party?

 

31. Name and address of third party (include street address, city, state, and ZIP code)

 

 

 

 

 

No (If "No," go

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

 

to Item 32,)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32. Name and address of physician first providing medical care (include street address, city, state, ZIP code)

33. First date medical

Mo. Day

Yr.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

care received

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

ZIP Code

 

34.Do medical reports

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

show employee is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disabled for work?

 

 

35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses?

Yes

No (If "No," explain)

36. If the employing agency controverts continuation of pay, state the reason in detail.

37.Pay rate when employee stopped work Per

Signature of Supervisor and Filing Instructions

38.A supervisor who knowingly certifies to any false statement, misrepresentation concealment of fact, etc. in respect of this claim may also be subject to appropriate felony criminal prosecution.

I certify that the information given above and that furnished by the employee on the reverse of this form is true to the best of my knowledge with the following exception:

Name of supervisor (Type or print)

Signature of supervisor

Date

 

 

Supervisor's Title

Office phone

 

 

39. Filing instructions

No lost time and no medical expense: Place this form in employee's medical folder (SF-66-D)

 

No lost time, medical expense incurred or expected: forward this form to OWCP

 

Lost time covered by leave, LWOP, or COP: forward this form to OWCP

 

First Aid Injury

 

 

 

 

 

 

 

Form CA-1

 

 

 

 

 

Revised October 2018

Print Form

 

Save Form

 

Reset Form

 

 

Page 2

Instructions for Completing Form CA-1

Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental statement to the form. Some of the items on the form which may require further clarification are explained below.

Employee (or person acting on the employees' behalf)

1a) Email address

14) Nature of injury

Injured workers should provide an email address when completing this form. Pursuant to policy established by the Department of Labor, Office of Workers' Compensation Programs (OWCP), Division of Federal Employees' Compensation, email communication on case specific inquiries is not allowed due to security concerns. However, obtaining claimant email addresses at the point of filing will allow OWCP to share general, non-case specific information with injured workers earlier in the claims submission process. As a longstanding policy and in an effort to protect the identities and personal information of claimants under the Federal Employees' Compensation Act, and to allow better tracking of incoming communications, we do not use two-way email as a primary method of interaction with claimants and their representatives.)

13) Cause of injury

Describe in detail how and why the injury occurred. Give appropriate details (e.g.: If you fell, how far did you fall and in what position did you land?)

Give a complete description of the condition(s) resulting from your injury. Specify the right or left side if applicable (e.g., fractured left leg: cut on right index finger).

15) Election of COP/Leave

If you are disabled for work as a result of this injury and filed CA-1 within thirty days of the injury, you may be entitled to receive continuation of pay (COP) from your employing agency. COP is paid for up to 45 calendar days of disability, and is not charged against sick or annual leave. If you elect sick or annual leave you may not claim compensation to repurchase leave used during the 45 days of COP entitlement.

Supervisor

As the time the form is received, complete the receipt of notice of

33) First date medical care received

injury and give it to the employee. In addition to completing

The date of the first visit to the physician listed in Item 31.

Items 17 through 39, the supervisor is responsible for obtaining

the witness statement in Item 16 and for filling in the proper codes

36) If the employing agency controverts continuation of

in shaded boxes a, b, and c on the front of the form. If medical

expense or lost time is incurred or expected, the completed form

pay, state the reason in detail.

should be sent to OWCP within 10 working days after is received.

COP may be controverted (disputed) for any reason; however,

The supervisor should also submit any other information or

the employing agency may refuse to pay COP only if the

evidence pertinent to the merits of this claim.

controversion is based upon one of the nine reasons given

If the employing agency controverts COP, the employee should

below:

be notified and the reason for controversion explained to him or

a) The disability was not caused by a traumatic injury.

her.

 

17) Agency name and address of reporting office

b) The employee is a volunteer working without pay or for

nominal pay, or a member of the office staff of a former

 

The name and address of the office to which correspondence

President;

from OWCP should be sent (if applicable, the address of the

c) The employee is not a citizen or a resident of the United

personnel or compensation office).

18) Duty station street address and zip code

States or Canada;

d) The injury occurred off the employing agency's premises and

 

The address and zip code of the establishment where the

the employee was not involved in official "off premise" duties;

employee actually works.

e) The injury was proximately caused by the employee's willful

 

19) Employers Retirement Coverage.

misconduct, intent to bring about injury or death to self or

another person, or intoxication;

Indicate which retirement system the employee is covered under.

f) The injury was not reported on Form CA-1 within 30 days

 

30) Was injury caused by third party?

following the injury;

 

A third party is an individual or organization (other than the

g) Work stoppage first occurred 45 days or more following

the injury;

injured employee or the Federal government) who is liable for

the injury. For instance, the driver of a vehicle causing an

h) The employee initially reported the injury after his or her

accident in which an employee is injured, the owner of a

employment was terminated; or

building where unsafe conditions cause an employee to fall, and

a manufacturer whose defective product causes an employee's

i) The employee is enrolled in the Civil Air Patrol, Peace Corps,

injury, could all be considered third parties to the injury.

Youth Conservation Corps, Work Study Programs, or other

 

32) Name and address of physician first providing medical

similar groups.

 

care

 

The name and address of the physician who first provided

 

medical care for this injury. If initial care was given by a nurse

 

or other health professional (not a physician) in the employing

 

agency's health unit or clinic, indicate this on a separate sheet

 

of paper.

 

Print Form

Save Form

Reset Form

Form CA-1

Revised October 2018

Page 3

Instructions for Completing Form CA-1 Continued

Employing Agency - Required Codes

Box a (Occupation Code), Box b (Type Code),OWCP Agency Code Box c (Source Code), OSHA Site Code

The Occupational Safety and Health Administration (OSHA) requires all employing agencies to complete these items when reporting an injury. The proper codes may be found in OSHA Booklet 2014, "Recordkeeping and Reporting Guidelines."

This is a four-digit (or four digit plus two letter) code used by OWCP to identify the employing agency. The proper code may be obtained from your personnel or compensation office, or by contacting OWCP.

Benefits for Employees under the Federal Employees' Compensation Act (FECA)

The FECA, which is administered by the Office of Workers' Compensation Programs (OWCP), provides the following benefits for job-related traumatic injuries:

(1) Continuation of pay for disability resulting from traumatic, job-related injury, not to exceed 45 calendar days. (To be eligible for continuation of pay, the employee, or someone acting on his/her behalf, must file Form CA-1 within 30 days following the injury and provide medical evidence in support of disability within 10 days of submission of the CA-1. Where the employing agency continue's the employee's pay, the pay must not be interrupted unless one of the provision's outlined in 20 CFR 10.222 apply.

(2) Payment of compensation for wage loss after the expiration

of COP, if disability extends beyond such point, or if COP is not payable. If disability continues after COP expires, Form CA-7, with supporting medical evidence, must be filed with OWCP. To avoid interruption of income, the form should be filed on the 40th day of the COP period.

(3)Payment of compensation for permanent impairment of certain organs, members, or functions of the body (such as loss or loss of use of an arm or kidney, loss of vision, etc.), or for serious defringement of the head, face, or neck.

(4)Vocational rehabilitation and related services where directed by OWCP.

(5)All necessary medical care from qualified medical providers. The injured employee may choose the physician who provides initial medical care. Generally, 25 miles from the place of injury, place of employment, or employee's home is a reasonable distance to travel for medical care.

An employee may use sick or annual leave rather than LWOP while disabled. The employee may repurchase leave used for approved periods. Form CA-7b, available from the personnel office, should be studied BEFORE a decision

is made to use leave.

For additional information, review the regulations governing the administration of the FECA (Code of Federal Regulations, Chapter 20, Part 10) or pamphlet CA-810.

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families.

(2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act.

(7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN), and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclosure all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the processing and adjudication of the claim you filed under the FECA.

Receipt of Notice of Injury

This acknowledges receipt of Notice of Injury sustained by (Name of injured employee)

Which occurred on (Mo. Day, Yr.)

At (Location)

Signature of Official Superior

Title

Date (Mo. Day, Yr.)

*U.S. GPO: 1999-454-845/12704

Print Form

Save Form

Reset Form

Form CA-1

Revised October 2018

Page 4

How to Edit Ca 1 Form Online for Free

It is easy to fill in the ca 10 spaces. Our software makes it nearly effortless to work with almost any PDF file. Below are the only four steps you need to take:

Step 1: On the page, press the orange "Get form now" button.

Step 2: Now, you are on the file editing page. You can add text, edit current information, highlight specific words or phrases, place crosses or checks, add images, sign the file, erase unwanted fields, etc.

All of the following parts are what you will need to fill out to have the ready PDF form.

completing html document your download stage 1

The application will require you to fill in the Employee Signature 15, I hereby authorize any physician, Date, Witness Statement 16, Name of witness, Address, Signature of witness, Date signed, City, State, ZIP Code, If you have a disability and are, and Form CA, 1 Revised October 2018 box.

part 2 to finishing html document your download

The program will ask you for data to conveniently fill in the box Official Supervisor's Report:, OW, CP Agency Code, OSHA Site Code, City, State, ZIP Code, City, State, ZIP Code, 19 Employee's retirement coverage, From:, CSR, S FER, S Other, and To:.

part 3 to filling out html document your download

You need to specify the rights and obligations of the sides in the Yes, No (If "No, City, City, State, ZIP Code, State, ZIP Code, Yes, Yes, No (If "No, Signature of Supervisor and Filing, I certify that the information, Per, and Name of supervisor (Type or print) section.

part 4 to completing html document your download

Finalize by looking at the following fields and filling them in as needed: No lost time and no medical, and Form CA, 1 Revised October 2018.

html document your download No lost time and no medical, and Form CA-1 Revised October 2018 blanks to fill

Step 3: Choose the Done button to ensure that your completed form is available to be transferred to every device you select or sent to an email you indicate.

Step 4: Create no less than two or three copies of your document to prevent any potential future challenges.

Watch Ca 1 Form Video Instruction

Ca 1 Form isn’t the one you’re looking for?

Related Documents

  • Csd 1 Form

    "... Appendix Manufacturer Installing Contractor Report for As Me csd Certification and Reporting CG 500 For Controls and Safety Devices This form is not part as me Cds 1998 Unit manufacturer name address zip telephone number ..."

  • Ca Rrf 1 Form

    "... Mail to Registry of Charitable Trusts Box 903447, Sacramento CA 94203 44470 Telephone 916 445 2021 Web Site Address http agca gov Charity Annual Registration Renewal Fee Schedule 11 Cal Code Reg Sections 301 311 ..."

  • California Dca Form Gsr 1

    "... Bureau of Automotive Repair License Unit Gold Shield Program 10240 Systems Parkway Sacramento, CA 95827 916255 3145 916255 255 4482 www Smog Check dc Ca gov Gold Shield Station Certification Application Instructions. This application covers ..."

  • California Llc 1 Form

    "... Revised may 15, 2013 changes in California business entity filings. All documents listing a corporation or limited liability company as an agent in service must contain the address. ..."

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .