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INSTRUCTIONS FOR COMPLETING DUTY STATUS REPORT (CA-17) SUPERVISOR: Complete Side A and refer the form to the physician to complete Side B. Fill in the address of the Employing Agency and send a copy of this report to the OWCP address noted below. Enter the OWCP file number in the top right corner. PHYSICIAN:
1 Αυγ 2014 · Download Fillable Form Ca-17 In Pdf - The Latest Version Applicable For 2024. Fill Out The Duty Status Report Online And Print It Out For Free.
Title: ca-17.pdf Author: DOLMAIN Created Date: 6/26/2019 9:31:59 AM
CA-1122 - Short Form 3rd Party Recovery . CA-1108 - Long Form Recovery for 3rd Party Injuries . FECA sf1199a - Direct Deposit Form . PS Form 3971 - (USPS Only) ... Postal Employees (USPS) TSA Employees Veterans Affairs (VA) Dept. of Defense (DOD) Homeland Security (DHS) Immigration & Customs (ICE)
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The CA-17 is a legal document that determines both an injured worker’s medical restrictions and entitlement to wage-loss compensation benefits. When completed, the CA-17 contains sensitive medical information and is protected under the Privacy Act. There are two sides to the CA-17: Side A is completed
INSTRUCTIONS FOR COMPLETING DUTY STATUS REPORT (CA-17) Complete Side A and refer the form to the physician to complete Side B. Fill in the address of the Employing Agency and the appropriate OWCP District Office in the spaces below. Enter the OWCP file number in the top right corner. SUPERVISOR:
