Ca 7A Form PDF Details

The U.S. Department of Labor's Office of Workers' Compensation Programs issues various forms critical to ensuring employees receive the benefits they are entitled to under the Federal Employees' Compensation Act (FECA). Among these, the CA-7A Form, or Time Analysis Form, plays a pivotal role, especially for those seeking compensation for periods of leave due to injury or illness attributable to their service as federal employees. Primarily, the CA-7A is designed to be used in conjunction with Forms CA-7 and CA-7b, to claim FECA compensation, including the repurchase of paid leave. It meticulously records and analyzes time for which compensation is claimed, breaking down the leave taken into categories like sick, annual, or other, and distinguishing between leave without pay and leave for which buyback is sought. Furthermore, it demands specificity about each claim, requiring detailed information such as the type of leave used, reasons for the leave, and, importantly, medical evidence supporting the need for such leave. Employees and Agency officials must navigate its requirements carefully, as accurate completion and certification of this document are crucial steps in the compensation claim process. This underscores the importance of understanding the structure and purpose of the CA-7A Form for both employees seeking compensation and the agencies processing these claims.

QuestionAnswer
Form NameCa 7A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesca 7a form, ca7a form department of labor, ca form online, ca 7a form owcp

Form Preview Example

Time Analysis Form

Reset

Print

U.S. Department of Labor

Office of Workers' Compensation Programs

Employee Statement - Please carefully read instructions on reverse before filling out this form.

1. Name of Employee: (Last, First, Middle)

 

2. SSN

 

3. OWCP File Number

 

 

 

 

 

 

4. Period Covered by This Form:

From:

 

To:

 

 

 

5. Total Hours Claimed

for LWOP: for Leave BuyBack

6.In ''Type of Leave Used'' column, use codes "S" = Sick, "A" = Annual, "O" = Other. If Compensation is claimed for date, indicate "Yes'' in ''Compensation Claimed'' column.

Date(s)

Compensation

Claimed?

Number of Hours

LWOP Worked Hol Leave

Type of

Leave

Used

Reason for Leave Use/Remarks (e.g., doctor visit, therapy, etc.)

Totals

Signature of Claimant

Date Signed

7. Agency Statement/Certification: I certify the above is accurate, except as follows:

Signature of Agency Official

Date Signed

Form CA 7a June 1996

Instructions for Completing Form CA-7A

Time Analysis

General: This form is used when claiming FECA compensation, including repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.

Instructions for Employee:

Blocks 1, 2, and 3: Self-explanatory.

Block 4: Indicate beginning and ending dates covered by this form. These must be the same as on Forms CA-7 and CA-7b.

Block 5: If claiming compensation for any dates detailed in block 4, state total number of hours claimed for leave without pay and total number of hours of leave. This should be at least 10 hours unless this is your final claim.

Block 6:

1st Column:

Show full date.

2nd Column:

For each date noted in column 1, state "Y" if you are claiming compensation

 

for that date and "N'' if you are not.

3rd, 4th,

Show the number of hours of LWOP, number of hours worked, paid

5th and 6th

Columns:

holiday hours, and number of hours of paid leave.

7th Column:

Using the legend provided, indicate the type of leave used.

8th Column:

State the reason you were off work. For each date for which compensation

 

is claimed, there must be medical evidence supporting entitlement.

Sign and Date Form and Submit to the Appropriate Agency Official.

Instructions for Employing Agency:

Block 7: Verify accuracy of hours and status for each date listed. If challenging entitlement for any date, attempt to resolve discrepancies prior to submitting claim to OWCP. If discrepancy cannot be resolved, indicate the specific basis for the challenge in the space provided.

How to Edit Ca 7A Form Online for Free

You'll find nothing troublesome concerning completing the ca form once you open our PDF editor. Following these simple actions, you can receive the ready PDF document within the least time possible.

Step 1: Seek out the button "Get Form Here" and press it.

Step 2: Once you've accessed the ca form edit page, you'll discover all functions it is possible to take with regards to your document within the upper menu.

To be able to prepare the file, enter the content the software will request you to for each of the following parts:

portion of spaces in ca 7a

Note the details in Totals, Signature of Claimant, Date Signed, and Agency StatementCertification I.

Completing ca 7a step 2

The application will require details to instantly fill out the section Signature of Agency Official, Date Signed, and Form CA a June.

stage 3 to completing ca 7a

Step 3: If you're done, choose the "Done" button to transfer the PDF form.

Step 4: You will need to generate as many duplicates of the file as you can to avoid potential issues.

Watch Ca 7A Form Video Instruction

Ca 7A Form isn’t the one you’re looking for?

Related Documents

  • Ca Llc 12R Form

    "... California secretary of State sb 1532 Annual Biennial Statements of Information Rev 01/11 2013 www Sos Ca gov Business be 916 6575448 Secretary of State business Programs Division statement of Information Box 944230 Sacramento CA ..."

  • Ca De35 Form

    "... De 35 Rev 14 13 Internet Page of Cu Notice to Employees Your employer must submit a copy of your employee's withholding allocation certificate form federal and de state to franchise tax board. If you ..."

  • Ca Form 540Nr

    "... You can enter total california earnings from your form 16 12 0013 or federal agi form 1040, line 37, 1040 or 1040 or ez lines 1040 and 1040 or 1040 or 1040 or 1040 or ..."

  • Ca Form 568

    "... Form 568 2020 side. 13671203 Limited liability company return on income. During this year, did any other person or entity gain control of or majority ownership of more than 50 interests in this LLC or ..."

Please rate Ca 7A Form

1 Votes

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 .