Fill and Sign the Time Period of Invoice Form

WHEN AN ON-THE-JOB INJURY OCCURS IMMEDIATE ACTION: EMPLOYEE MUST: 1. Technicians, who are injured on the job, must notify their supervisors of any injury and circumstances of said injury immediately. The technician, supervisor, or someone acting in his/her behalf can fill out the FORM CA-1 – Notice of Traumatic Injury. If your supervisor is not in the vicinity, report your injury to anyone in the area. They can be used as a witness, even if they did not observe the accident, if they knew you were unhurt prior to the incident. It is a requirement of Department of Labor that your injuries are reported, and then submitted on-line on a CA-1. A CA-16 must accompany the claimant to the physician within 48 hours of the incident, and CA-17 within 10 working days. The CA-1 can be submitted to OWCP on-line the day of the injury at the following address: https://diucs.cpms.osd.mil/static_java_edi_sup.html; The CA-2 (Notice of Occupational Health Injury/Disease) can also be submitted on line. The CA-16 and CA-17 need to go to the medical facility for the Doctor to fill out his portion (fill out this agencies portion first), and then returned to the HRO. 2. If emergency medical treatment is required a co-worker or family member may report the injury on behalf of the employee. ***TAKE FORMS ALONG TO THE MEDICAL FACILITY*** SUPERVISOR MUST: 1. Insure the employee’s immediate medical needs are met. Either the supervisor or a co-worker should accompany the employee when seeking medical attention. 2. Provide the employee with the following forms: IMMEDIATELY: (a) initiate a FORM CA-1 – Notice of Traumatic Injury (to be completed by the employee immediately, when possible, or within 2 working days at the latest, if the employee is incapacitated, this action may be taken by someone acting on his/her behalf. Send to the HRO. IMMEDIATELY: (b) Initiate a FORM CA-16 – Request for Examination and/or Treatment (must be completed by the supervisor within 4 HOURS of the request for medical treatment and submitted to HRO within 10 working days). Whenever possible, this form should be provided the employee when he/she seeks initial medical treatment to facilitate the completion of Part B by the attending physician. (c) FORM CA-17 –Duty Status Report (only needed if the employee is unable to return to duty or must be placed in a “light duty” status pending recovery from the injury). Part A to be completed by the supervisor and Part B by the attending Physician. (d) HCFA 1500 or OWCP 1500 – Health Insurance Claim Form to be completed by the health care facility and submitted through HRO to OWCP. ATTN: HRO/OWCP, HQ UTAH NATIONAL GUARD, PO BOX 1775, DRAPER UT 84020-1776 SECONDARY/FOLLOW-UP ACTION: EMPLOYEE MUST: 1. Contact your supervisor and advise him/her of your medical condition and the doctor’s instructions regarding treatment and recovery. 2. If there will be a loss of duty time other than the day of the injury, you must discuss your leave status with your supervisor to insure proper reporting to the Payroll Section. 3. At a MINIMUM and employee should insure a FORM CA-17 – Duty Status Report is provide to the supervisor through the attending physician every 2 weeks during a period of incapacitation or light duty. SUPERVISOR MUST: 1. Review the following forms and insure all are thoroughly completed, then forward to the Human Resources Office/Office of Workmans’ Compensation. WITHIN 10 WORKING DAYS (a) CA-1 – Notice of Traumatic Injury. Be certain the employee, the witness, and the supervisor have signed in the applicable areas. Do not take this form to the care provider. WITHIN 10 WORKING DAYS (b) CA-16 – Request for Examination and/or Treatment. This form should be forwarded the HRO upon receipt. 2. If there will be a loss of duty time other than the day of an on-the-job injury, the employee’s leave options are (a) Sick Leave (b) Annual Leave (c) Continuation of Pay (COP). A total of 45 days of COP are granted to recover from an injury without using sick or annual leave, beginning with the day after injury. COP is counted in full day increments and counted continuously through weekends and holidays just like military leave. The 45 days must be used within a 45-day period beginning the first day the employee returns to duty. COP days used should be coded (LT) for pay purposes. (d) The first day of injury counts as admin leave and must be coded LU to trigger COP. A letter authorizing COP must be submitted to the pay branch by the HRO. Days, or portions of day covered under COP should be coded LT. ALWAYS REMEMBER! Please make certain you inform the medical facility that this is a FEDERAL WORKERS’ COMPENSATION CLAIM for THE DEPARTMENT OF LABOR. Otherwise they might send it to the State office or bill your insurance and there will be a delay in getting claims paid. Also, please send all ORIGINAL paperwork through your servicing personnel office (HRO). This way we can keep track of all your paperwork and help the claim be paid in a more efficient manner. *NOTE: OWCP does not recognize signatures or documents from Physician Assistants