Notes for Web Readers
This Handbook contains hyperlinks to Workers' Compensation
forms that are available for download from the Department
of Labor's Web site. Employees with access
to InForms® Filler may obtain these forms in a machine-fillable
format.
Effective February 1, 2001, the Department's Workers'
Compensation policy is set forth in Chapter
6-1 of the Human Resources Order, DOJ 1200.1. |
Table of Contents
Introduction
What Type Of Condition Does My Employee Have?
How Do I Get My Employee Medical Attention?
How Do We File The Claim?
How Do I Cover My Employee's Absence?
Keep Up Communication
How Do I Mark The Time And Attendance Records?
The Employee Can Return To Light Duty, Now
What?
The Condition Is Permanent And My Employee
Is Not Able To Return To The Former Job
I Don't Agree With My Employee's Report Of
Injury
Samples And Examples
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Introduction
Your employee has come to you and reported an injury on the job. What
are you supposed to do? What type of a condition is it, and what
paperwork is required? This handbook will walk you through the
basic steps of getting your employee the needed medical care, and
then guide you through the sometimes complicated and confusing
steps of reporting and documenting your employee's compensation
case. We'll touch on how you can assist your employee in returning
to the workforce, which will help you get the workload accomplished
and reduce compensation expenses.
While reading through this handbook, remember, you are not alone. Anytime
you have questions or need assistance in dealing with a workers' compensation
issue, you can call your Injury Compensation Program Administrator
for assistance and advice. Points of contact for the program,
worksheets, checklists, and samples are included in the appendices
of this booklet to assist you with your responsibilities.
This handbook does not cover all the details of the Federal Employee's
Compensation Act or all the benefits employees may be due. Rather
it is intended to provide quick and simple guidance that will help
you through the majority of the situations you will encounter if
one of your employees suffers a job related injury or disease.
What Type Of Condition Does My Employee
Have?
Most work-related medical conditions fall into two categories (1)
traumatic injury (Form CA-1), and (2) occupational disease (Form
CA-2). You will need to be familiar with these categories so you
can help your employee complete the correct paperwork. The easiest
way to identify the difference between the categories is to identify
how long it took the medical condition to occur.
Traumatic Injury (Form CA-1): If
the condition happened in the course of one work shift,
the condition is an injury. Examples: cut finger; tripped and
fell; hit by forklift, etc. Sometimes the reported condition may
not seem like an injury, such as mental stress or back strain. However,
if the employee identifies the condition as occurring in the course
of one work shift, the condition is still considered to be a traumatic
injury.
Occupational Disease (Form CA-2): If
the condition happened because of events in more than one
work shift, the condition is an occupational disease. Examples: back
strain from unloading trucks for the past two weeks; carpal tunnel
from daily use of computer keyboard, etc.
Note: Your employee may complain of
suffering a recurrence of a prior injury or disease and state the
desire to file for benefits under the prior claim. A recurrence
is defined as a return of symptoms related to the original injury
or disease for no explainable reason other than there was a prior
medical condition. If a new event or series of events (e.g., bent
over to tie shoes, moved boxes, etc.) causes a return in symptoms,
the condition must be treated as a new injury or disease as described
above even if the exact same part of the body is affected. If
symptoms do begin for no explainable reason other than the prior
injury or disease, the employee can file for a recurrence under
the prior claim. Recurrence claims are not detailed in this handbook
(contact your servicing personnel office for details).
How Do I Get My Employee Medical Attention?
Regardless of the category of the medical condition, your first
concern will be to determine if your employee needs immediate medical
care. If immediate care is required, assist in making arrangements
for your employee to go to the nearest health care facility or
to their private health care provider. Make sure your employee
can safely drive. If the employee cannot drive, ensure that transportation
is available, or call an ambulance. You can authorize the medical
treatment by telephone to the private provider or hospital, and
follow-up with the CA-16 to the medical facility within 48 hours.
If the situation is not an emergency, you will want to take time
to discuss the situation with your employee. The Public Health
Service (PHS) health care facilities can provide medical attention,
and forms to report the work-related condition. Remember that
you cannot authorize medical treatment in occupational disease
claims without prior Office of Workers' Compensation (OWCP) approval.
Forms required to obtain medical care are:
-
Traumatic injuries within the last 48 hours. Form
CA-16 - Authorization for Examination and/or Treatment. This
form guarantees payment to the care provider.
-
Occupational Diseases or traumatic injuries that
occurred more than 48 hours ago. Form CA-20 -
Attending Physician's Report. Because it is harder
to prove that occupational diseases or injuries that are
not recent were caused at work, a form that guarantee's
payment for something that may not be the government's
responsibility would not be appropriate. If the employee's
claim is accepted, the medical bill will be paid even
though a CA-16 was not issued.
It is recommended that you provide your employee with a form CA-17 -
Duty Status Report, or the position description and SF-78
- Certificate of Medical Examination, along with a
light duty availability letter to give to the physician. These
forms inform the doctor of the type of physical requirements
your employee regularly performs; inform the physician that
you can accommodate light and/or part-time duty; and provide
the doctor a means to communicate to you what the employee can
safely do; when the employee can return to light duty work;
and when the employee can resume regular duty.
This procedure is critical in establishing sensitivity at the beginning
of any future claim.
Your employee may object to reporting for medical care; however,
it will be important to the claim to have early medical reports.
If you offer the employee an opportunity for care and the employee
refuses to go, document the refusal with the claim.
We Got Medical Care, Now How Do We File
The Claim?
You should encourage your employees to report all work-related
conditions to you and to file the CA-1 or CA-2, even if there
is no lost time or medical expense. The Department of Labor (DOL)
considers claims to be 'allowable' if they are reported within
three years; however, it will be easier for the employee to prove
his or her case if paperwork is submitted as soon as possible after
the injury or disease occurs. Even if you do not agree with your
employee's report of a work-related condition or event, you still
need to work with the employee to report and file the CA-1 or CA-2. Then
you may challenge the claim. (For more information on challenging
the claim, see the section below - "I Don't
Agree With My Employee's Report Of Injury")
Traumatic Injuries: Use Form CA-1. The
front side of the form must be completely filled out and signed
by the injured worker. If the injury is so severe that the worker
cannot fill out the report, a supervisor, family member, or friend
can fill it out and sign it. The reverse side of the form must
be completely filled out and signed by you, the immediate supervisor.
Occupational Disease: Use Form CA-2. The
front side of the form must be completely filled out and signed
by the worker. The reverse side of the form must be completely
filled out and signed by you, the immediate supervisor.
NOTE:
In many instances, some of the blocks on Forms CA-1 and CA-2 will
not apply to your situation. Rather than leave them blank (which
will result in them being returned to you and delaying the employee's
claim), indicate "N/A".
Compensation paperwork must be processed through you, the immediate
supervisor, your servicing personnel office, and to the DOL within 10
workdays from the day the employee submits the paperwork
to you. Upon receiving the documents, fill out and return the
receipt portion to your employee. It is then your responsibility
to promptly forward the original claim forms to
your servicing personnel office within the allotted time frame. Your
servicing personnel office will complete agency coding, process
the case file, and forward claims to the DOL. Submit any additional
paperwork (CA-16, CA-17, CA-20, witness statements, challenges,
etc.) with the claim or as soon as they become available.
You may receive medical updates, bills, etc., on your injured worker
after the original claim has been sent off. Submit all these original
documents to your servicing personnel office to be included in
the agency case files and to be processed through the DOL.
How Do I Cover My Employee's Absence?
Benefits to cover absences differ based on whether the employee
suffered a traumatic injury or an occupational disease. We'll
cover each separately.
Continuation Of Pay (COP) For Traumatic Ijury: Your
employee may be eligible for uninterrupted pay beyond the date
of injury without charge to leave. This benefit is called continuation
of pay and is granted if all the following conditions
are met:
-
The employee suffered a traumatic injury and filed form CA-1 within
30 days from the date of the injury.
-
The employee has provided you with valid medical
documentation to show that the inability to work
in any capacity is due to the injury.
-
The absences due to the injury began within 90 days from
the date of injury.
-
The employee's absences do not exceed a total of 45
calendar days of COP. COP counts in whole day
increments. If the employee works partial days, but is
entitled to COP for the remainder of the work day, the
few hours of COP count as a whole day of the 45 day entitlement.
-
If the employee returns to work, but has a recurrence of
disability within the 90 days, the employee may receive
COP for any of the remaining 45 day period he/she has not
yet expended, even if the disability extends beyond the 90
day period.
NOTE: More information and a worksheet to
assist you in tracking COP is provided at Appendix B. Medical
verification of the employee's disability along with a copy of
the worksheet should be annotated and submitted to your servicing
personnel office at the end of each pay period during which your
employee used COP. This action should be coordinated with the timekeeper
prior to coding the time sheets to ensure that the employee's pay
is not adversely impacted. This enables your servicing personnel
office to assist in tracking the entitlement.
Denial Of Continuation Of Pay: You may believe
that your employee should not get COP. Be aware that you can only
deny COP based on the following reasons (if COP already began,
terminate it) :
-
The disability is caused from an occupational disease rather
than a traumatic injury.
-
The employee is not a U.S. citizen or a resident of the U.S.
or Canada.
-
The injury occurred off government premises and the employee
was not involved in official "off premise" activities.
-
The injury was caused by the employee's willful misconduct.
-
The injury was not reported on CA-1 within 30 days following
the injury.
-
Work stoppage first occurred 45 days or more after the injury.
-
The employee initially reported the injury after his/her
employment was terminated.
-
The employee is enrolled in the Civil Air Patrol, Peace Corps,
Job Corps, Youth Conservation Corps, Work Study Program,
or other similar groups covered by special legislation.
-
The employee is a volunteer working without pay or for nominal
pay or persons appointed to the staff of a former president.
Note: If your employee is eligible for COP,
but the claim is later denied, DOL will direct the Department of
Justice to recoup the COP and change the COP absences to leave
or leave without pay. Also, COP can be terminated if the employee
refuses a job within his/her restrictions and limitations, or fails
to respond to your job offer.
Absences After Continuation Of Pay Expires: If
the employee was eligible for COP, but is absent beyond the 45
day limit or does not become disabled within the 90 day window,
the employee has two options:
-
The employee can use sick or annual leave to continue uninterrupted
pay, or:
-
Elect to go on Leave Without Pay and submit form CA-7 -
Claim for Compensation on Account of Traumatic Injury
or Occupational Disease to request wage loss
payments from the DOL. Form CA-7 alerts the DOL that
the employee is not receiving any income and initiates
wage loss pay. Form CA-7 is also used to claim absences
at two week intervals if the absences continue beyond
the period claimed on the initial form CA-7. The employee
has the responsibility to submit medical documentation
to support that the ongoing absences are related to the
work-injury and should anticipate at least a 3-4 week
delay before they receive pay from DOL. The delay can
be longer if a claim is incomplete or controversial. Employees
who elect to use their own leave can later repurchase
the leave with their compensation benefits. Information
on this option (Leave Buy Back) is explained at Appendix
C. Form CA-20 "Attending Physician's Report" should be
filed at the same time as the CA-7. If the employee is
losing time from work, these forms should be filed with
OWCP five working days prior to the end of the 45 day
COP period.
Absences Due To Occupational Disease: COP is
not a benefit for occupational disease. If the employee
cannot work due to the claimed condition, two options are
available:
-
Use sick or annual leave to continue uninterrupted pay or:
-
Elect to go on Leave Without Pay and submit forms CA-7 to
request wage loss benefits from the DOL. Form CA-7 initiates
wage loss pay, and continues wage loss at bi-weekly intervals
if the absences continue beyond the initial period claimed
on the form CA-7. The employee has the responsibility to
submit medical documentation (Form CA-20 and CA-20a) to demonstrate
that the absences are related to the claimed work-condition. Because
occupational disease claims take longer to adjudicate, it
can take several weeks or even several months before the
employee can expect to receive pay from the DOL. As a result,
most employees elect to use their own leave and then later
repurchase the leave with their compensation benefits. This
option (Leave Buy Back) is explained in Appendix C.
Note: If disability continues beyond the
date shown on the initial CA-7, subsequent Form CA-7s should be
submitted 5 to 7 days before the end of the period claimed on the
last claim form submitted. Form CA-20a (Attending Physician's
Supplemental Report) should be filed with the subsequent CA-7.
Keep Up Communication
-
Make regular contact with your employee to let him/her know
that he/she is missed at work and offer your assistance with
any job or claim concerns. Your employee is anxious and
nervous about what is happening with his/her job and future
and your regular communication can work more magic in expediting
your employee's recovery and return to work than any medical
science.
-
Send form CA-20 or CA-20a, as well as form CA-17, to the
doctor every two weeks or as often as needed to keep updated
on your employee's work status.
-
Keep your managers and the injured employee's co-workers
informed of what is happening. By doing so, you will receive
their support and cooperation in keeping up the extra workload
and, when the time comes, in bringing the injured worker
back to duty. Bringing the worker back to a positive environment
will help your employee continue down the road to recuperation
and/or help in the adjustment to job rehabilitation.
-
Keep your servicing personnel office, and the DOL informed
by forwarding all documentation regarding your injured worker
for inclusion in the case files.
How Do I Mark The Time And Attendance Report?
Date of Injury: For traumatic injuries
only, if the employee cannot return to work following
the injury and the injury occurred after the beginning of the
work shift, the employee is carried on the time and attendance
report as completing the regular shift. This day is a "freebie".
Continuation of Pay: Continuation of pay
is coded LT which stands for Disability- Pay. Again,
this code may only be used if the employee suffered a traumatic
injury, filed a CA-1 within 30 days from
the date of injury, has provided you medical documentation to
support total disability due to the injury within 10 days, and
does not exceed 45 calendar days of COP, and disability
begins within 90 days from the date of injury.
COP may be used in increments. Example: Your
part-time (6 hours per day) employee has a release to return to
work, but must go to physical therapy two hours per day. The time
and attendance record would show 4 hours regular duty and 2 hours LT. Remember
that even though only two hours of COP were used on this day, it
still counts as whole day of the 45 days entitlement of COP.
Leave Without Pay: Leave Without Pay due
to an injury or occupational disease is coded KD which
stands for Disability-Nonpay. This puts the employee in an approved,
leave without pay status and flags it as being a work-related medical
condition. Unlike other leave without pay absences, the time
missed from work will not count against the employee's tenure benefits,
such as within grade increases and leave accrual.
The Employee Can Return To Light Duty, Now
What?
This is the key to effectively managing your injured worker's case. It
is DOJ policy to have injured workers return to work as soon as
possible. The reasoning behind this policy is that all
the benefits your employee receives from the DOL are charged back
to the agency. Since you are "paying" your employee,
you may as well arrange to get some productivity
for your money, and at the same time help your employee's recuperation
and rehabilitation by helping him/her feel needed and a part of
the organization. Therefore, you will want to do everything possible
to help your employee return to work by looking at the following
options:
-
Can my employee return to his/her former job without modification?
-
Can my employee return to his/her former job with modification?
-
Can my employee return to another job in the organization?
-
Can a job be created to accommodate my employee's restrictions?
Since you are most familiar with your work area, you are the first
line of making accommodation for your employee to return to work. Any
such accommodation must be documented in writing to ensure that
you, the employee, and the DOL know that accommodation has been
made and that it is reasonable and within the employee's capabilities. If
accommodation is not documented, and you have to later separate
your employee, or if your employee just doesn't report for duty, he/she
will likely be eligible to resume compensation.
Note: Sample light duty job offer and fill-in-the
blank job offer forms are included at Appendix D to document job
accommodation. You will need to coordinate these actions with
your servicing personnel office.
As soon as your employee returns to work in any capacity, including
light duty or part time, complete a light duty statement or a statement
that light duty is not required by the doctor's release and send
this form to your servicing personnel office. A sample can be
found in Appendix D. This light duty letter formally documents
that your employee's
status of being " totally disabled" has terminated.
The Condition Is Permanent And My Employee
Is Not Able To Return To The Former Job
Chances are you cannot afford to let your worker be indefinitely
assigned to his/her regular position, drawing full wages when he/she
can only perform limited duties. Steps can be taken to reassign
the injured worker to another position so you can better manage
your manpower allocations. If the reassignment results in lower
wages or less hours of work for the employee, a claim can be filed
for the difference in wages with DOL. Contact your servicing personnel
office for guidance.
If you cannot easily identify another position, you will want to
work with your servicing personnel office to see if another job
can be developed.
In extreme cases, you may not be able to accommodate your injured
worker and you may have no choice but separation. However, this
could potentially be a million dollar decision and should only
be considered as a last resort. Once your employee is separated,
he/she will likely be eligible to resume compensation benefits
(even if separated through retirement) and may receive these compensation
benefits for the rest of his/her life. As
mentioned before, these benefits will be charged back to
the agency, with you receiving no productivity in return.
I Don't Agree With My Employee's Report
Of Injury
The circumstances surrounding the reported injury or disease may
arouse your suspicions that the condition is not work-related.
If this occurs, remember that as a supervisor, you are obligated
to assist your employees in processing their paperwork in a timely
manner, and your failure to do so can be punishable under the law. Neither
you nor the agency can determine if an employee should file a claim
or receive benefits. The DOL has the sole authority to approve
or disapprove claims and to determine if benefits will be paid.
Rather than impeding the employee's rights to file a claim, gather
witness statements (e.g., if anyone heard the employee state that
he hurt himself over the weekend, the employee works another job,
etc.) and facts to challenge the claim. The sooner you accomplish
this the better, because once the DOL approves a case or pays benefits,
it is difficult, if not impossible to have them change their decision. If
you plan to challenge a case, but don't have time to gather your
information before you must process the claim paperwork, attach
a note to the claim and your servicing personnel office can formally
request an extension (normally 30 days) from the DOL so they won't
adjudicate the claim without the additional facts.
You can anticipate that the DOL will contact you and the employee
in a conference call to settle any conflict in the presented facts,
or write to you and ask for more details on the case. Respond
fully to such requests, and within the time frames given by the
DOL. Without your answers, they will consider only the information
on hand, and your employee may have sent in enough information
to get the case approved despite your initial efforts.
Although it is a slow and sometimes frustrating process, you should
always take the effort to challenge suspicious claims.
The pay-off in money saved from one successfully challenged claim
will more than offset the time you invest in doing a conscientious
and thorough job of presenting the facts.
Now That It's Over. Congratulations!! In
addition to your demanding job as a supervisor, you have successfully
managed your injured workers'
situation. Hopefully, he/she made it back to work and you are
receiving some type of productivity for your efforts.
At this time you will want to remember that the successful management
of the case took teamwork. You probably had subordinates that
pitched in and did more than their fair share to get the job done
and keep your mission going while you were shorthanded. Remember
those employees when giving performance ratings, with awards, and
words of appreciation, as appropriate.
Your actions will enhance a positive work environment and foster
the teamwork spirit that gets you through these tough times.
Appendix A
Points Of Contact
For Workers' Compensation Questions/Issues
Appendix B
Rules For Issuing And Tracking Continuation
Of Pay (COP)
-
Use only for traumatic injuries. (injury
happened during the course of a single workday/shift)
-
COP cannot exceed 45 calendar days.
-
COP counts in whole day increments. Example: Employee works
seven hours then misses two hours for an appointment related
to the injury. Time and Attendance report will reflect 7
hours of work and 2 hours of COP, but a whole day of the
45 day entitlement will be used.
-
If medical documentation indicates a period of absence which
includes work and non-work days, all the days count against
the 45 day entitlement.
-
COP must be used within 90 days from the date of injury or within
90 days from the first day the employee returns to work if
any of the 45 days has not been used and additional absences
occur. Exception: The COP absences can go beyond the 90
day window only if it involves a continuous period
of absence that started within the 90 day window, however,
the total days used still cannot exceed 45 days.
-
You can use the following worksheet to track COP for each
injured employee. Medical verification of the employee's
disability along with a copy of the worksheet should be annotated
and can be submitted to your servicing personnel office at
the end of each pay period during which your employee used
COP. This action should be coordinated with the timekeeper
prior to coding the time sheets to ensure employee's pay
is not adversely impacted. This enables your servicing personnel
office to assist in tracking the entitlement.
-
To be eligible for COP, the employee must:
-
File Form CA-1 within 30 days from the date of injury.
-
Provide medical documentation to support
they are totally disabled for work due to the job injury.
Name:
Date Of Injury: Salary:
|
Day No. |
Date COP Used/Hrs. |
Medical Backup Sent To Personnel |
Day No. |
Date COP Used/Hrs. |
Medical Backup Sent To Personnel |
01 |
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24 |
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02 |
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25 |
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03 |
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26 |
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04 |
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27 |
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05 |
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28 |
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06 |
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29 |
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07 |
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30 |
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08 |
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31 |
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09 |
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32 |
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10 |
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33 |
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11 |
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34 |
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12 |
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35 |
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13 |
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36 |
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14 |
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37 |
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15 |
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38 |
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16 |
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39 |
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17 |
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40 |
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18 |
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41 |
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19 |
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42 |
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20 |
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43 |
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21 |
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44 |
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22 |
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45 |
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COP for Intermittent Employees
All employees, regardless of schedule or appointment type are eligible
for COP if they meet the entitlement criteria. Because intermittent
employees do not have a set work schedule, the following worksheet
is used to compute their benefit:
Worksheet For Computing Continuation Of
Pay For Intermittent, When Actually Employed (WAE) or Part-Time
Employees
Employee____________________________
Claim No._________________ DOI ____________
1. Weekly Pay Rate:
Total the employee's hours worked during the year
preceding the injury and multiply by the employee's
hourly rate. Divide the total by the number of weeks
the employee worked during the year.
____________
2. 150 Day Rule:
Use employee's average hourly rate multiplied by 8
hours, multiplied by 150. Divide by 52 weeks. _____________
Salary for a full week of COP is based on the HIGHER of block 1
or 2.
Note: For partial weeks of COP, subtract
actual earnings during the week of COP from the established weekly
rate.
Sample:
Average Weekly Wage:
An employee who earns $7.00 per hour worked 720 hours during 43
weeks in the year immediately preceding the injury. $7 times 720
hours = $5,040. Then $5,040 divided by 43 = $117.20.
150 Day Rule:
$7 times 8 hours = $56 times 150 = $8,400. $8,400 divided by 52
= $161.53.
For COP purposes, this employee would receive $161.53 per week. If
the employee worked during a COP week, any salary earned would
be subtracted from the COP due the employee.
Appendix C
Leave Buy Back
Employees who elect to use sick or annual leave during their
period of disability to avoid interruption of income, may claim
compensation for the period of disability and "buy back" (subject
to approval of the employing agency) the leave used.
Once the injury or disease claim is approved by the Office of
Workers' Compensation Programs (OWCP), the employee may submit
a request to "buy back" leave used due to disability from the
job-related injury/disease. The request is made on Form CA-7.
The following information is provided to assist employees in
their decision:
-
An employee without dependents is entitled to compensation
at the rate of 2/3 their regular salary. With dependents,
the employee is entitled to 3/4 of their regular salary. Because
leave is paid at 100 percent of salary and compensation
is paid at a percentage, the employee will owe
the agency money or the leave repurchase.
-
The gross amount paid for sick or annual leave during
the disability is the amount the payroll office will have
to recover from the employee. The employee will be required
to have the compensation check forwarded to payroll and
to make arrangements with payroll to pay the difference
between the compensation check and the money they received
while on leave. The employee will recoup most, if not
all, of their repayment at year end tax time because the
leave pay was taxed and the compensation pay is tax-free.
-
The higher of the pay rate on date of injury, date
of recurrence, or date disability
began is used by OWCP in computing compensation.
-
Any sick or annual leave used during the 45-day COP period
cannot be used for buy back purposes unless the employee
was not entitled to COP.
-
If annual leave is to be recredited and
it exceeds the maximum permissible carry over balance,
the excess is subject to forfeiture.
-
Since all the leave previously used must be converted
to Leave Without Pay (LWOP), all leave earned during the
period of disability used for leave buy back is nullified.
-
Holiday pay is included in the leave buy back if the employee
was in a LWOP status on the last hour of the day before
a holiday and at the beginning of the business day after
a holiday.
-
Medical evidence supporting the period of disability must
be submitted with the Form CA-7, if the disability has
not already been documented.
If the employee has an irregular work schedule, or if leave
being repurchased was not used continuously, the employee should
use the following worksheet to document the dates and hours
of absence, the type of leave used and to total the time claimed. The
worksheet must be reviewed by the supervisor.
To Be Attached To Forms CA-7
& CA-8
Name:________________________________________________
Claim No:_____________________________________________
Dates
List each date |
Hours Worked |
Hrs Leave A/L |
Hrs Leave S/L |
Hrs LWOP |
Comments |
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Use this form when the employee works part-time and claims compensation
for a portion of the day. It should be used for leave buy-back
requests. Be sure to list holidays and indicate how many hours
claimant was paid.
Signature:_______________________________________ Date:___________________________
Appendix D
Sample Offer Letter Of Light Duty
1. This confirms our conversation on (date) in which you were
offered a light duty assignment, the duties of which conform
to the physical limitations imposed by (doctor's name), who
is treating you for your on-the-job injury of (date of injury). The
following is provided regarding the light duty job:
Location of job:
Pay rate and schedule will be .
Description of physical requirements and duties of the position:
This will be a full time, sedentary, position but you will be
allowed to sit or stand as you require. The physical demands
are those of typical office work, including lifting less than
15 pounds. You will be required to sort material within an
organization to appropriate personnel using alphabetical, numerical,
chronological, or subject-matter filing system. You will answer
the phone and relate messages both orally and in writing. Typing
is not required for this position. You will maintain a filing
system and follow simple oral and written instructions.
If you require handicap parking, you may request a permit to
park in a designated space in order to minimize the distance
you are required to walk from your car to your work site each
day.
The job is available ___(beginning date)_________________________
.
2. Please return your acceptance or declination of this light
duty job offer to this office no later than ____________________________
.
Supervisor
Signature
I accept _________ I
decline________
__________________________________________ ______________________
Employee Signature Date
Sample Letter To Attending
Physician
Memorandum For: Attending Physician
From:
Subject: Light Duty for Injured Employees
Employee: ___________________
Date Of Injury: ___________________
This employee has claimed an on-the-job injury or work-related
illness and selected you as the attending physician.
Form CA-20, Physician's Report, for you to document your findings
is enclosed.
If the Office of Workers' Compensation Programs (OWCP) determines
the condition is not work-related, any medical expenses related
to the condition are the employee's personal responsibility.
(see attached position description)
Please send the completed form CA-20 and billing form HCFA 1500
to the address indicated below to expedite any payment you may
be due:
Agency/Component
Attn: XXXXXXXX
Address
We are able to provide light duty or sedentary work
for employees who are unable to return to their regular duties. This
light duty will be in accordance with your written recommendations
and can be as light as answering telephones 2 hours a day. In
view of this policy, we would appreciate your consideration
of light-duty for this employee when completing the form. If
you feel the employee cannot perform any type of work, please
send us a prognosis of when return to work may be possible
in either a limited or full capacity.
If you need assistance with claims, please call me at (XXX)
XXX-XXXX. We appreciate your assistance in this matter.
Injury
Compensation Program Administrator
Sample Fill-In-The
Blank Light Duty Job Offer
MEMORANDUM FOR:_______________________________
SUPV OF:_______________________________
FROM: (servicing personnel office)__________________________________________
SUBJECT: Light Duty Position Offer
1. The referenced employee has been released to return to duty. Please
complete the information below if light duty is available.
Have the employee sign this letter and return it to
this office within 10 working days. Attach any documentation
( physician report, etc.). If the employee is on regular
duty, please sign line 1 below.
2. Contact me at ________________ if you have questions concerning
the above. Thank you for your assistance with this claim.
________________________________________________________
Employee Relations Assistant
MEMORANDUM FOR SERVICING PERSONNEL OFFICE
FROM:________________________________________________
SUBJECT: Written Confirmation of Light Duty/Regular Duty Work
1. The above referenced employee is no longer/never
was on light duty (Circle one). If the employee
has been released to light duty
but has not returned to duty, please mail this offer
to his home. The due date for this letter is unchanged.
____________________________________________ __________________________________________________
Employee Signature/DATE Supervisor's
Signature/DATE
2. This is written confirmation of the light duty made available
to you upon your return to duty on _______________________.
3. Work schedule will be _____________________________________________________.
Rate of pay will be __________________.
You will be on light duty from_____________________________________to________________________________________________.
4. Based on the physical limitations imposed by your doctor,
the light duties described below will continue until your
private physician returns you to regular duty.
Your duties consist of:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
5. The physical requirements and the number of hours indicated
for these duties are:
ACTIVITY HRS ACTIVITY HRS
ACTIVITY HRS ACTIVITY HRS
SITTING ______ WALKING _____
LIFTING _____ BENDING_____
STANDING____ SQUATTING____
CLIMBING____ KNEELING_____
6. Lifting is restricted to _________________ pounds.
_________________________________
Supervisor's Signature
I accept______________, decline____________ your offer of light
duty work. Response due no later than 14 calendar days.
6. I understand that if I refuse a suitable offer of work, my
compensation benefits may be terminated.
______________________________________
_______________________________
Employee Signature
Date
Appendix E
Compensation Forms And Purposes
The following compensation forms information has been provided
on only those forms you are likely to use.
CA-1 -
Federal Employee's Notice of Traumatic Injury and Claim for Continuation
of Pay/Compensation.
Use for traumatic injury - employee was hurt because of a single
event or within one workday.
CA-2 -
Notice of Occupational Disease and Claim for Compensation. Use
for occupational disease or illness claims - medical condition
developed over more than one workday (i.e. carpal tunnel, skin
disease).
CA-2a -
Federal Employee's Notice of Recurrence of Disability and Claim
for Pay/Compensation. Use for recurrence of injury or occupational
disease - medical condition has flared up for no other explainable
reason other than a previous work-related condition.
CA-7 -
Claim for Compensation on Account of Traumatic Injury or Occupational
Disease. Used for the following purposes:
- To claim lost wages when continuation of pay expires on a traumatic
injury, and to claim wage loss on occupational disease claims.
- Use to initiate leave buy backs.
- Use to claim a scheduled award (employee has reached maximum
medical improvement but has suffered a permanent loss or impairment
to a part of their body).
- Use to keep compensation for wage loss coming in on a regular
basis for employees on leave without pay.
CA-16 - Authorization for Examination and/or Treatment. This
form guarantees the physician payment for care provided to the
injured employee.
CA-17 -
Duty Status Report. This form allows the physician to keep you
updated on your employees work restrictions and/or duty status.
OWCP will only work with original forms. Send originals
to your servicing personnel office as soon as possible.
Failure to submit claim forms in a timely manner by employee (30
days) jeopardizes the employee's benefits. Failure to submit claim
forms in a timely manner by supervisor (10 days) can result in
a fine and/or imprisonment (20
CFR 10.16). Submit information to challenge claims rather
than avoid or delay the process.
Incomplete forms cause unnecessary delays and causes complications
at your servicing personnel office and at OWCP. Look at and address every block. Indicate
N/A if information is not pertinent. Call your servicing personnel
office if you need assistance.
To learn
more about the Federal Employees' Workers'
Compensation Program, visit the Department of Labor's
Web site. |
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