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Federal Notice of Traumatic Injury and Claim for Continuation

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STOP PAYMENT NOTICE

(Individual as Claimant)

Name of Party Giving Notice:

Street Address:

City, State and Zip Code:

Relationship to other parties:

Statement re Nature of work provided:

Person/Party to whom work provided:

Claimant's Estimate of total amount in value of the work to be provided: $

Claimant's Demand for unpaid work through date of this notice: $

Name of owner or reputed owner:

Street Address:

City, State and Zip Code:

Name of direct contractor:

Street Address:

City, State and Zip Code:

Name of construction lender:

Street Address:

City, State and Zip Code:

Site of the Improvement:

Street Address:

City, State and Zip Code:

Legal Description:

Date:

 

 

Signature

 

 

Print or Type Name

I, declare under penalty of perjury under the laws of the State of California, that I have read the above STOP NOTICE, and I know it is true of my own knowledge, except as to those things stated upon information and belief, and as to those I believe it to be true.

Executed 20 at

 

 

Declarant

 

 

Type or Print Name

Note: CA Civil Code §8506 provides that a Stop Notice:
1. To an Owner shall be given to the Owner or the Owner's architect;
2. To a Construction Lender to the manager or other responsible party at the office or branch of the lender administering or holding the construction funds.

PROOF OF NOTICE DECLARATION
(Civil Code § 8118)

I, declare that I have served copies of the Above by (check appropriate box below):

a. By personally delivering copies to:

Name:

Title:

At: Street Address:

City, State and Zip Code:

On: 20 at am / pm.

b. By Certified, Express, or Registered Mail Service, postage prepaid addressed to:

Name:

Title:

At: Street Address:

City, State and Zip Code:

On: 20 at am / pm.

See attached documentation provided by the US Postal Service or express mail service showing the date of delivery and the name of the person accepting delivery; tracking record or other documentation from express carrier showing attempted delivery or delivery of the notice; or, in the event of non-delivery, the returned envelope itself.

I declare under penalty of perjury that the foregoing is true and correct.

Signed at California on 20

 

 

Signature

 

 

Print or Type Name

ATTACH SERVICE LIST OF CERTIFIED OR REGISTERED MAIL WHEN RETURNED, OR PHOTOCOPY OF POST OFFICE RECORD OF DELIVERY OF RECEIPT.

A notary public or other officer completing the certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California

County of

On 20 before me,

the officer), personally appeared who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

 

Signature

(Seal)

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What this Federal Notice of Traumatic Injury and Claim for Continuation is

The Federal Notice of Traumatic Injury and Claim for Continuation (commonly filed on OWCP CA-1) is the federal form employees use to report a sudden work-related injury and request continuation of pay or compensation. It documents the event, the employee’s statement, medical details, and the supervisor’s report so the Office of Workers' Compensation Programs can determine initial eligibility and begin benefit processing. The form initiates the administrative claim pathway and records evidence needed to support wage replacement, medical coverage, and return-to-work planning.

Why this notice matters for claim continuity and benefits

Filing the Federal Notice of Traumatic Injury and Claim for Continuation promptly preserves entitlement to continuation of pay and speeds benefit decisions while creating a formal record for medical and administrative review.

Why this notice matters for claim continuity and benefits

Primary users and stakeholders who complete or receive the form

Who completes and handles this form varies across the claim lifecycle; several parties are routinely involved.

  • Federal employees: File the form to report a traumatic workplace injury and request continuation of pay.
  • Supervisors / managers: Review, complete their portion, and forward to agency HR or OWCP as required.
  • HR / Occupational Health: Process claims, collect supporting medical documentation, and submit to OWCP.

Step-by-step: completing and submitting the notice

Use this short sequence when preparing the Federal Notice of Traumatic Injury and Claim for Continuation to avoid delays and missing information.

  • 01
    Gather evidence: Collect witness names, incident details, and medical records before starting the form.
  • 02
    Complete form: Enter required fields accurately, attach medical documentation, and sign where indicated.
  • 03
    Supervisor review: Ask your supervisor to verify their section and add any agency comments.
  • 04
    Submit to HR/OWCP: Forward final form and attachments to agency HR or OWCP per local routing rules.

How to configure a digital workflow for this notice

Set up a simple electronic workflow so the form moves from employee to supervisor to HR/OWCP with required fields and audit logging.

Field Configuration
Authentication method Email link plus optional SMS code for signer verification
Required fields Make employee name, SSN/ID, date of injury, description, and signature mandatory
Attachment settings Allow upload of medical reports and photos in PDF, DOCX, or image formats
Routing rules Auto-route to supervisor then HR; log timestamps for each step

Typical submission route from employee to claims processing

A standard path ensures accountability: employee completes form, supervisor confirms, HR verifies attachments, and the agency forwards records to OWCP for adjudication.

  • Employee completes: Fills form, attaches medical proof, and signs to show intent to claim.
  • Supervisor verifies: Confirms incident facts and forwards the document with comments.
  • HR compiles: Reviews, adds agency records, and prepares submission packet.
  • OWCP receives: Agency or employee submits to OWCP for benefit determination.

Technical and format requirements for eSubmission

Choose a platform that supports common file formats, audit trails, and signer authentication suitable for health-related claims.

  • File formats: PDF, DOCX, JPEG, PNG supported for attachments
  • Authentication: Email link, SMS code, or stronger methods for sensitive data
  • Integrations: Connectors for Google Workspace, Microsoft 365, HR systems

Time expectations and processing cadence

Timely reporting and submission reduce the risk of denied or delayed benefits; agencies may have internal deadlines that complement administrative processing.

Report to supervisor:

Notify your supervisor as soon as possible after the incident, ideally the same day

File the form:

Complete and submit the notice promptly to preserve claim continuity and payroll actions

Agency processing:

HR or claims office typically reviews within days to weeks depending on workload

OWCP adjudication:

Benefit determination can take several weeks—medical records and clear evidence speed review

Appeals timeline:

Follow agency guidance for reconsideration or appeal deadlines after initial decisions

Common mistakes that delay processing

  • Incomplete injury description: vague or missing facts that prevent establishing work connection and cause follow-up requests.
  • Missing signatures or dates: unsigned forms or wrong date formats can trigger rejection or processing delays.
  • Insufficient medical documentation: lack of timely medical reports or clinician notes often stalls eligibility determinations.
  • Incorrect routing: sending the form to the wrong office or failing to include required attachments prolongs adjudication.

Consequences of incorrect or late filing

Benefit delay: Processing and payments delayed
Denial risk: Claim may be denied for lack of evidence
Loss of COP: Continuation of pay eligibility may be lost
Administrative burden: Additional documentation and appeals required
Potential discipline: False statements can trigger agency action
Fraud penalties: Criminal/civil penalties for intentional misrepresentation

Essential data elements required on the notice

Employee name: Full legal name
ID number: SSN or agency ID
Date/time: Date and time of injury
Injury details: Concise factual description
Supervisor info: Name and contact details
Signature: Signed and dated by claimant

Core sections and what each captures

A professional Federal Notice of Traumatic Injury and Claim for Continuation includes clearly labeled sections for incident facts, claimant details, medical information, supervisory input, compensation request, and required signatures.

Claim details

Captures incident date, time, location, and a short factual narrative of how the injury occurred to establish cause.

Employee statement

First-person account of the event and immediate effects to support the causal link with federal duties and medical findings.

Medical information

Records, diagnoses, treatment dates, and provider details that substantiate injury severity and need for continuation of pay or compensation.

Supervisor report

Supervisor confirms work-related context, notes witness information, and documents any immediate agency response or safety actions taken.

Continuation request

Explicit field to request continuation of pay (COP) or wage-loss compensation with relevant dates and payroll impact details.

Routing & signature

Designated signature blocks and routing instructions ensure the form reaches HR and OWCP with an audit trail.

How this federal claim compares with similar documents

Compare purpose and typical filing context so you use the correct form when reporting injury or occupational illness.

Criteria Federal traumatic injury (CA-1) Occupational disease (CA-2)
Primary use sudden injury report illness from repeated exposure
Timing critical immediate reporting recommended may involve longer discovery period
Medical proof contemporaneous treatment notes detailed occupational history
Submission destination owcp owcp with more medical documentation

eSignature vendor pricing and capability snapshot for completing federal notices

Choose a provider that supports required formats, audit trails, and strong authentication. The table lists starting prices and common capability markers to compare options.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year No cap No cap No cap

Realistic examples of how this notice is used

Two concise scenarios show common situations where the Federal Notice of Traumatic Injury and Claim for Continuation is necessary and how documentation affects outcomes.

On-the-job slip

An employee slips on a wet floor and fractures a wrist during duty hours

  • Witness and photo evidence recorded
  • Clear contemporaneous medical notes and timely supervisor reporting enabled early continuation of pay and faster claim intake with minimal follow-up.

Sudden equipment failure

A technician is struck by an unexpected tool failure and reports a shoulder injury immediately

  • Supervisor documents equipment incident
  • Detailed incident description and prompt medical care led to timely OWCP review and expedited initial benefits.

Frequently asked questions about filing and eSubmission

Answers to common questions on whether the notice can be e-signed, who must sign, and how to correct or supplement a submitted claim.


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