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supply of the basic forms needed for the proper recording and reporting of injuries. Pamphlet CA-136, obtainable from OWCP, lists the forms to be stocked by the agencies; and also tells where the forms may be obtained.
(b) The basic forms cited in this chapter are: Form No.
(1) CA-1 ....................... Federal Employee's Notice of
Traumatic Injury and Claim for
Occupational Disease and Claim
for Compensation. (3) CA-2............. Notice of Employee's Recurrence of
Disability and Claim for Pay/
Compensation. (4) CA-3 ................ Report of Termination of Disability
and/or Payment. (5) CA-4.......... Claim for Compensation on Account
of Occupational Disease. (6) CA-5 .............
Claim for Compensation by Widow,
Widower and/or Children. (7) CA-50...... Claim for Compensation by Parents,
Brothers, Sisters, Grandparents,
or Grandchildren. (8) CA-6 ............... Official Superior's Report of
Employee's Death. (9) CA-7 ............ Claim for Compensation on Account
of Traumatic Injury. (10) CA-8 ......... Claim for Continuing Compensation
on Account of Disability. (11) CA-16 ......... Request for Examination and/or
Treatment. (12) CA-17.
Duty Status Report. (13) CA-20 ....
Attending Physician's Report. (14) CA-20a ........ Attending Physician's Supplemental
Report (c) Copies of the forms enumerated in this paragraph are available for public inspection at the Office of Workers' Compensation Programs, Employment Standards Administration, U.S. Department of Labor, Washington, D.C. 20211. (40 FR 6877, Feb. 14, 1975, as amended at 41 FR 2, Jan. 2, 1976)
Act constitute the exclusive remedy against the United States for employ. ment related injuries or deaths. The injury or death of an employee gives rise to no right to recover damages from the United States exclusive of the Act. $ 10.23 Penalties.
(a) Any person who makes a false statement to obtain Federal employ. ees' compensation or who accepts compensation payments to which he or she is not entitled is subject to a fine of no more than $2,000 or imprisonment for no more than one year, or both.
(b) Any person charged with the responsibility of making reports in connection with an injury who willfully fails, neglects, or refuses to do so; knowingly files a false report; induces, compels, or directs an injured employ. ee to forego filing a claim; or willfully retains any notice, report, or paper required in connection with an injury, is subject to a fine of no more than $500 or imprisonment for no more than one year, or both.
Subpart B-Notice of Injury and
Claim for Compensation, Administrative Procedures
NOTICE OF INJURY OR DEATH
§ 10.21 Waiver of Compensation rights in
valid. No official superior or other person is authorized to require an employee or other claimant to enter into any agreement, either before or after an injury or death, to waive his or her right to claim compensation under the Act. No waiver of compensation rights shall be valid.
$ 10.100 How to file a notice of injury.
(a) Traumatic injury. Whenever any employee sustains a traumatic injury which he or she believes to have occurred while in the performance of duty, such employee shall immediately give written notice of the injury to his or her official superior. If the employee is unable to give such notice for any reason, such notice may be give by any person with knowledge of the injury on behalf of the injured employee. Form CA-1, Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation, is approved by the Office for the giving of such notice.
(b) Occupational disease. Whenever an employee has reason to believe that he or she is suffering from an employ. ment related occupational disease or disability which has not been traumatic in onset, such employee or any
§ 10.22 Exclusiveness of remedy.
The benefits provided to employees and to survivors of employees by the
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(This book contains Parts 1 to 399)
Part CHAPTER 1–Office of Workers' Compensation Programs,
Department of Labor .......
NOTE: Other regulations issued by the Department of Labor appear in 20 CFR Chapters IV, V, VI and VII, 29 CFR Subtitle A and Chapters II, IV, V, XVII and XXV, 30 CFR Chapter I, and 41 CFR Chapters 29, 50 and 60.
CHAPTER 1-OFFICE OF WORKERS'
DEPARTMENT OF LABOR
CROSS REFERENCE: Employees' and employers' taxes under Federal Insurance Contributions Act and Excise tax on employers under Federal Unemployment Tax Act: See Internal Revenue, 26 CFR Part 31.
SUBCHAPTER A-ORGANIZATION AND PROCEDURES
Performance of functions under this chapter..........
SUBCHAPTER B-FEDERAL EMPLOYEES' COMPENSATION ACT
Claims for compensation under the Federal Em
ployees' Compensation Act, as amended ............... Compensation for disability and death of noncitizen Federal employees outside the United States............
SUBCHAPTERS C-E (RESERVED)
SUBCHAPTER F-COMPENSATION FOR INJURY, DISABILITY, DEATH, OR ENEMY DETENTION OF EMPLOYEES OF CONTRACTORS WITH THE UNITED STATES
General administrative provisions
or compensation funds .......
SUBCHAPTER G-COMPENSATION FOR INJURY, DISABILITY OR DEATH OF CIVILIAN AMERICAN CITIZENS INCURRED WHILE DETAINED BY OR IN HIDING FROM THE IMPERIAL JAPANESE GOV. ERNMENT