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This form is provided for the purpose of obtaining a duty status report for the employee named below. This request does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any previous authorization issued in this case.
1 sie 2014 · Easily create and download a Duty Status Report (Form CA-17) in PDF or Word format at Templateroller.com. Fill out online or download blank form for free.
Title: ca-17.pdf Author: DOLMAIN Created Date: 6/26/2019 9:31:59 AM
31 paź 2008 · View, download and print fillable Ca-17 - Duty Status Report in PDF format online. Browse 1 Ca-17 Form Templates collected for any of your needs.
Form CA-17 - Duty Status Report: This form is provided for purpose of obtaining a medical duty status report for IW. It may be issued initially with Form CA-16.
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:
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
