When Injured at Work Checklist - USDA
|United States Department of Agriculture |When Injured at Work Checklist – |
|Marketing and Regulatory Programs |Traumatic Injury |
| |
|Employee: |
| |
|Forms I need: |
| |
|CA-1, Federal Employees Notice of Traumatic Injury and Claim for continuation of Pay and |
| |
|CA-16, Authorization for Treatment and/or Examination |
| |
|I went to the doctor/emergency room within 48 hours of my accident/injury and used a CA-16 |
| |
|The doctor completed page 2 of the CA-16 and returned it to me. |
| |
|I completed and submitted the CA-1and CA-16 to my supervisor, with all medical documentation. |
| |
|I have a doctor’s note stating when I can return to work if the doctor determined that I cannot work for a period of time because of my work for a period of |
|time because of my accident/injury (this is required for Continuation of Pay). |
| |
|Supervisor: |
| |
|Once I was notified of the employee’s illness/disease, I made sure the employee had the following forms to file a worker’s compensation claim: |
| |
|CA-1, Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay, and |
| |
|OSHA-301, Injuries and Illnesses Incident Report |
| |
|A doctor’s note stating when he/she will need to be on leave and a return to work date. |
|(Continuation of Pay) |
| |
|I have reviewed the CA-1, and I: |
| |
|Agree with what the employee has written regarding the accident/injury. |
| |
|Disagree with what the employee has written regarding the illness/disease. Therefore I am providing a written statement describing the events to best of my |
|knowledge. |
| |
|When the employee submitted the CA-1 and/or CA-16 and the OSHA-301 to me, I signed the forms where indicated for supervisor signature, within 3 days of |
|receiving the forms. |
| |
|I forwarded the forms to appropriate the WC Representative. |
MRP Form 41-R Local Reproduction Authorized
MAY 2012
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- smart goals at work examples
- things to do when bored at home
- how to get organized at work templates
- questions to ask when looking at houses
- things to consider when looking at colleges
- what to do when bored at home
- what to do when bored at school
- things to do when bored at night
- questions to ask when looking at colleges
- wheezing when breathing at night
- what to do at work when bored
- things to do when bored at work