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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:
Title: ca-17.pdf Author: DOLMAIN Created Date: 6/26/2019 9:31:59 AM
11 lip 2023 · CA-17 Duty Status Report. ( ) ⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0046 can be found here: 2024-08-20 - No material or nonsubstantive change to a currently approved collection. 2023-07-11 - Revision of a currently approved collection. Document [pdf] Download: pdf | pdf. Please wait...
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.
Form CA-17 For common positions in EA, have a pre-prepared CA-17 with the left side completed for the injured worker to provide to their physician. On Form CA-17, the EA should indicate light duty work is available.
It is recommended that you take a Form CA-17 - Duty Status Report with you to give to your physician. This form provides your supervisor and OWCP with interim medical reports containing information as to your ability to return to any type of work.
Date Form CA-17 Rev. Jan. 1997 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 the appropriate OWCP District Office in the spaces below.
