BOP Program Statement 1601.07 § 12

Individual case files are protected under the Privacy Act of 1974, and only the IW, their

representative (if any), and CWCU can access DOL electronic files. All personnel who are

involved with OWCP must comply with DOL/GOVT-1, Privacy Act of 1974, and Systems of

Records regulations. IW’s seeking copies of their official FECA file can access it through

ECOMP.

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REFERENCES

Program Statements

None Referenced

Federal Statutes

5 U.S.C. § 8101

18 U.S.C. § 286

18 U.S.C. § 287

18 U.S.C. § 1001

18 U.S.C. § 1920

18 U.S.C. § 1922

Privacy Act of 1974, 5 U.S.C. § 552a

The False Claims Act, 31 U.S.C. § 3729-3733

Federal Regulations

Federal Employees' Compensation Act, 20 CFR Part 10

29 CFR § 1630.14(c)

Other References

U.S. Department of Labor, Office of Workers’ Compensation Programs. (n.d.). FECA Claimant

User Guides.

U.S. Department of Labor, Office of Workers’ Compensation Programs. (n.d.). Supervisor User

Guides.

Other Forms

Form CA-1 Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of

Pay/Compensation

Form CA-2 Notice of Occupational Disease and Claim for Compensation

Form CA-7 Claim for Compensation

Form CA-7a Time Analysis Form

Form CA-16 Authorization for Examination and/or Treatment

Form CA-17 Duty Status Report

OWCP-5a Work Capacity Evaluation Psychiatric/Psychological Conditions

OWCP-5b Work Capacity Evaluation Cardiovascular/Pulmonary Conditions

OWCP-5c Work Capacity Evaluation Musculoskeletal Conditions

SF-1199A Direct Deposit Sign-Up Form

SF-2810 Notice of Change in Health Benefits Enrollment

ACA Standards

Performance-Based Standards and Expected Practices for Adult Correctional Institutions (5th

Edition): 5-ACI-1B-17.

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Performance-Based Standards and Expected Practices for Adult Local Detention Facilities (5th

Edition): 5-ALDF-7D-16.

Standards for the Administration of Correctional Agencies, 2nd Edition: 2-CO-1C-05.

Records Retention Requirements

Requirements and retention guidance for records and information applicable to this program are

available in the Records and Information Disposition Schedule (RIDS) on the Bureau’s intranet

site.

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Attachment A. Commonly Used DOL Forms

Form Form Title Purpose Prepared By When Submitted Completed

Number Forms Sent To

CA-1 Federal The staff has sustained a traumatic Staff or By staff or representative Supervisor by

Employee’s Notice injury during single day or work shift someone within 30 days, but will meet staff or someone

of Traumatic Injury that is likely to result in a medical acting on statutory requirements if filed acting on staff’s

and Claim for charge against the compensation fund. staff’s no later than three years after behalf; then to

Continuation of behalf. the injury, to the employer. OWCP by AR.

Pay/Compensation The employer submits

completed documents within

10 workdays following receipt

of the form from the staff.

CA-2 Notice of Notifies supervisor of an Staff or By staff within 30 days, but Supervisor by

Occupational occupational disease and serves as the someone will meet statutory staff or someone

Disease and Claim report to OWCP when: (1) the disease acting on requirements if filed no later acting on staff’s

for Compensation is likely to result in a medical charge staff’s than three years after last behalf; then to

against the compensation fund; (2) the behalf; witness exposure to the conditions OWCP by AR.

staff loses time from work on any day (if any); causing the disease or

after the injury date, whether the time is supervisor. awareness of a relationship

charged to leave or leave without pay; between the disease and

(3) disability for work may federal employment; by

subsequently occur; (4) permanent supervisor within 10 workdays

impairment appears likely; or (5) following receipt of the form

serious disfigurement of the face, head, from the staff.

or neck is likely to result.

CA-7 Claim for Claims compensation for: (1) leave Staff and By staff as soon as Supervisor by

Compensation without pay due to injury-related supervisor or possible following wage loss staff or someone

disability or absence to obtain medical injury or awareness of impairment; acting on staff’s

treatment; (2) repurchase of sick or compensation by supervisor or injury behalf; then to

annual leave used due to injury-related specialist. compensation specialist within OWCP by AR.

disability or absence to obtain medical five workdays of receipt from

treatment; (3) loss of wage-earning staff.

capacity resulting from the work injury;

(4) schedule award for permanent

impairment resulting from the work

injury.

CA-16 Authorization for Authorizes an injured Part A: Part A: By supervisor within Part A: Given to

Examination and/or staff to obtain immediate examination Authorizing four hours of a traumatic Staff.

Treatment and/or treatment from a physician Official. injury. May be issued up to

chosen by the staff for an on-the-job one week after injury. Completed form

injury and provides OWCP with initial sent to OWCP.

medical report. Treatment may be Part B: Part B: By attending physician

obtained from a local hospital or Attending or medical facility as promptly

physician. physician. as possible after initial

examination.

CA-17 Duty Status Report Provides supervisor and OWCP with Side A: Promptly upon completion of Original to

interim medical report containing Authorizing examination. employer; copy

information on staff’s ability to return Official. to OWCP mail

to work and physical limitations. Side B: address.

Attending

physician.

CA-20 Attending Provides medical support for claim and Attending Promptly upon completion of OWCP, if

Physician’s Report is attached to Form CA-7 (can also be physician. examination. attached

obtained or submitted separately); to form CA-7;

provides OWCP with medical OWCP.

information. If a narrative medical

report or Form CA-16 has been

submitted to OWCP within the past 10

days, this form is not needed.

OWCP-5 Work Capacity Provides supervisor and OWCP with Attending Promptly upon completion of Original to

(a-c) Evaluation (Psych, interim medical report containing physician and/ examination. employing

Cardio/ Pulmonary, information on staff’s ability to return or specialist agency; copy to

or Ortho) to work and physical limitations. OWCP.

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