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> In Reply Refer To:

In Reply Refer To:

1400-810(HR-220)**P**

Information Bulletin No. 2006-

To: All Field Officials

From: Chief Human Capital Management Project Director

Subject: Employee Casualty Guide for Managers and Supervisors

Attached is a copy of the Employee Casualty Guide. This guide is
designed for managers, supervisors, and other administrative personnel
to use when a work-related casualty occurs on the job. It provides
step-by-step guidance on how to handle casualties which occur on the job
and who is responsible for completing the assignments.

A quick-reference laminated card for supervisors and team leaders to
insert into their wallets and use when a casualty occurs in the field or
office, will be available from your Human Resources Office.

This edition of The Employee Casualty Guide for Managers and Supervisors
supersedes the August 2000 version.

Marilyn H. Johnson

1 Attachment

1 - Casualty Guide

cc: HRO's

Safety Managers

**[TABLE OF CONTENTS]{.underline}**

**APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii**

**FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii**

**INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .1**

**FIRST LINE SUPERVISOR/LEAD AND/OR SENIOR RANKING**

**OFFICIAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3**

**RESPONSIBLE MANAGEMENT OFFICIAL (RMO) . . . . . . . . . . . . . . . .
. . . . . . . . . . .6**

**SAFETY OFFICE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . .. . . . . . . . . . . . . . . . . . . . . . . . . . .8**

**LAW ENFORCEMENT OFFICE. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 10**

**FAMILY LIAISON. . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11**

**HUMAN RESOURCES OFFICE. . . . . . . . . . . . . . .. . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 12**

**OFFICE OF PUBLIC AFFAIRS. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 15**

**SURVIVOR BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . .** . . . . . . . . . . . . . . . . . .**16**

**i**

**NHRMC**

**[APPENDICES]{.underline}**

**APPENDIX 1 - CASUALTY LOG (1400-113)**

**2 - PERSONAL EMERGENCY INFORMATION CARD**

**(1400-71)**

> **3 - SUPERIOR'S REPORT OF EMPLOYEE'S DEATH (CA-6)**

**4 - FINAL SALARY CLEARANCE REPORT**

**(1340-2)**

**5 - NOTICE OF LAW ENFORCEMENT OFFICER'S DEATH**

**(CA-722A)**

> **6 - SAMPLE LETTER OF CONDOLENCE**
>
> **7 - SAMPLE LETTER EXPLAINING SF-50**
>
> **8 - LISTING OF POTENTIALLY INVOLVED FEDERAL**

**AGENCIES**

**ii**

**NHRMC**

**FOREWORD**

This handbook is designed to assist managers, supervisors, and other
administrative personnel when an employee dies on the job as a result of
an accident/incident or of natural causes. We recommend that you
maintain this *Guide* so that you will have a readily available
reference if an employee dies on the job.

To facilitate handling a situation in which an employee dies on the job,
you may request, from your Human Resources Office, a quick reference
laminated card for supervisors and team leaders to use. Please carry the
card with you at all times while you are on official duty.

This handbook does not cover employees who are injured on the job. For
information on how to handle employees who are injured on the job,
please refer to your Safety Manager or your Human Resources Office for
assistance.

The *Guide for Reporting Serious Law Enforcement Incidents* should be
used, in conjunction with this handbook, to determine if the incident
should immediately be reported to the Department of the Interior.

> **iii**

**NHRMC**

**INTRODUCTION**

**[PURPOSE]{.underline}** The purpose of this handbook is to provide
basic guidance to managers, supervisors, and administrative personnel
when a Bureau of Land Management (BLM) employee dies on the job.

**[APPLICABILITY]{.underline}** The provisions of this handbook apply to
all management and administrative personnel who have some involvement in
processing an employee casualty.

**[DEFINITIONS]{.underline}** The terminology most frequently used in
this handbook is defined as follows:

> **Casualty** ‑ A death of a BLM employee as a result of a job‑related
> accident/incident, an illness, or natural causes.
>
> **Casualty Log (BLM Form 1400-113) -** Contains a record of all
> specific information and personal contacts made relative to the
> casualty.
>
> **DASHO** ‑ Designated Agency Safety & Health Official. The DASHO for
> BLM is the Chief Human Capital Management Project Director, located in
> Washington, D.C.
>
> **DOL -** Department of Labor
>
> **EAP ‑** The Employee Assistance Program.
>
> **Emergency Card (Form 1400-71) -** Includes information regarding
> notification of next of kin. Check with your Support Services Division
> regarding where these forms are maintained.
>
> **Family Liaison** ‑ A BLM employee who will serve as the BLM's
> representative to the family. If a law enforcement official is the
> casualty, a law enforcement officer will be appointed as the family
> liaison.
>
> **Final Salary Clearance Report (Form 1340-2, January 2004)** -
> Completion is required for all separating employees before final
> salary and lump sum payments are processed.
>
> **HRO** -- Human Resources Office
>
> **1 NHRMC**
>
> **SAIT** - Serious Accident Investigation Team
>
> **Payroll Operations Office** - An organizational entity of the DOI
> National Business Center, located at:
>
> ***U.S. Department of the Interior***
>
> ***National Business Center***
>
> ***Payroll Operations Division***
>
> ***P. O. Box 272030***
>
> ***Denver, CO 80227-9030***
>
> **OSHA ‑** Occupational Safety and Health Administration
>
> **Responsible Management Official (RMO)** ‑ RMOs may be one of the
> following, depending on the supervisor's organizational location in
> the BLM:
>
> State/Associate State Director
>
> Center Directors
>
> Assistant Directors, WO
>
> Field/Center Managers or Assistants

Special Agent-in-Charge

**[ELEMENTS OF]{.underline}** This guide consists of the following basic
elements:

**[THE HANDBOOK]{.underline}**

> A. A description of the responsibilities of each of the involved
> management and administrative personnel.
>
> B. Step‑by‑step procedures which must be followed by management and/or
> administrative personnel.
>
> C. A list of the benefits for which the survivor
>
> may be eligible.

**[RESPONSIBILITIES]{.underline}** Responsibilities are designated as
follows:

> A. Program Responsibility ‑ The Director, Deputy
>
> Director, State/Center Directors, and Assistant Directors retain
> overall responsibility for the safety of employees.
>
> B. Program Implementation ‑ Manager/supervisors and other
> administrative staff are responsible for ensuring that employee
> casualties are taken care of in accordance with established
> procedures.

**2 NHRMC**

[**FIRST-LINE SUPERVISOR, TEAM LEADER,** **AND/OR SENIOR RANKING
OFFICIAL**]{.underline}

**[OBJECTIVE]{.underline}** To delineate the responsibility of the
first-line supervisor and/or their designee whenever an employee
casualty occurs.

**[RESPONSIBILITIES]{.underline}**

**First-Line Supervisor** The supervisor has overall responsibility for
securing the site and locating information on whom to notify of the
employee's death.

**Leader/Ranking Employee** The leader and/or ranking employee of the
work group is responsible for assuming control of the situation when an
on‑the‑job casualty occurs and [a supervisor is not
present.]{.underline}

**[PROCEDURES]{.underline}** The following procedures must be followed
when an employee casualty occurs:

**On‑the‑Job Accident** A. In the supervisor's absence, the lead and/or
ranking employee must do the following:

> \(1\) Account for all employees in the group.
>
> \(2\) Call 911 to activate emergency response services and provide
> basic first aid, if trained.
>
> \(3\) Secure the casualty site so that evidence is not disturbed and
> Government and/or personal property are not unlawfully removed.

\(4\) Advise the supervisor of the casualty.

B. The supervisor must do the following:

> \(1\) Accomplish A (1)‑(4) above if present at the
>
> casualty site.
>
> \(2\) Immediately obtain the specific information regarding the
> casualty (who, what, when, where, and how) and record it in the
> casualty log (BLM Form 1400-113, Appendix 1)
>
> .

**3 NHRMC**

> \(3\) Using the Personal Emergency Information Card (BLM 1400‑71)
> (Appendix 2), identify the names of individuals who must be notified
> and record this in the casualty log. Once completed, the casualty log
> should be submitted to the RMO for their use in notifying the
> next-of-kin.
>
> \(4\) If a Personal Emergency Information Card is not available,
> co‑workers, neighbors, or close friends may provide names of
> individuals who should be contacted. The name, telephone number, home
> address, and relationship to the deceased should be recorded in the
> casualty log.
>
> \(5\) Notify the second-level supervisor and the RMO of the accident,
> if they are not one and the same.
>
> \(6\) Prepare an Official Superior's Report of
>
> Employee's Death, (CA‑6), (Appendix 3).
>
> \(7\) Prepare a Request for Personnel Action (Standard Form 52)
> showing date of death.
>
> \(8\) Using the automated time and attendance system, annotate the
> employee's death.

(9) Ensure that the Final Salary Clearance Report (Form 1340-2 -
    Appendix 4) is completed.

> \(10\) Work with the HRO to arrange for EAP to provide counseling to
> affected employees, if it is determined that a counselor is necessary.

**Illness/Natural Causes** When an employee dies on the job as a result
of illness or natural causes, the following steps should be followed:

> \(1\) Call 911 to activate emergency response services and provide
> basic first aid if trained.
>
> \(2\) Advise the supervisor of the casualty.

**4 NHRMC**

> \(3\) Using the Personal Emergency Information Card (BLM 1400‑71),
> identify the names of individuals who must be notified.
>
> \(4\) If a Personal Emergency Information Card is not
>
> available, co‑workers, neighbors or friends may
>
> provide names of individuals who should be
>
> contacted. The name, telephone number, home address, and relationship
> to the deceased should be
>
> recorded in the casualty log.
>
> \(5\) Notify the second-level supervisor and the RMO of the death, if
> they are not one and the same.
>
> \(6\) Prepare a Request for Personnel Action (Standard Form 52)
> showing date of death.
>
> \(7\) Using the automated time and attendance system, annotate the
> employee's death.
>
> \(8\) Ensure that the Final Salary Clearance Report (Form 1340-2) is
> completed.

(9) Work with the HRO to arrange for EAP to provide counseling to
    employees, if it is determined that a counselor is necessary.

> A CA-6 should **[ONLY]{.underline}** be completed when the employee
> dies as a result of injury in the performance of his/her duties or
> because of an employment-related disease.

5.  **NHRMC**

[**RESPONSIBLE MANAGEMENT OFFICIAL (RMO**)]{.underline}

**[OBJECTIVE]{.underline}** To delineate the procedures which the RMO
must follow when a casualty occurs. The *Guide for Reporting Serious Law
Enforcement Incidents* should also be consulted to determine if the
incident is a serious law enforcement incident which should immediately
be reported to the Department of the Interior. If it is a serious law
enforcement incident, the procedures set forth in that guide should also
be followed. This would be reported on form CA-772a (appendix 5)

**[PROCEDURES]{.underline}** Once the first-line supervisor has notified
the RMO that an employee casualty has occurred, the RMO assumes
responsibility and assures that the following steps are accomplished:

**On‑the‑Job Casualty** A. Notify the State/Center Director and/or WO
AD, who in turn will notify the Director, WO‑100.

B.  Ensure that the BLM Special Agent-in-Charge (SAC) has been notified.

    C. Notify the Human Resources Office to coordinate efforts to handle
    processing.

> D. Ensure that the name(s) of the deceased [are not
> released]{.underline} until the next-of-kin have been notified.
>
> E. Determine who will serve as the Family Liaison, should the family
> decide they would like such a
>
> representative. If the casualty is a law enforcement officer or fire
> employee, it is preferable that the family liaison be assigned from
> the same program area.
>
> F. Notify the next of kin. When notifying the next of kin, the RMO may
> want to take someone with them. The RMO should provide the next of kin
> with the name and telephone number of the family liaison and
>
> the HRO in the event they need assistance in completing paperwork,
> etc.
>
> **6 NHRMC**
>
> G. Notify the State Safety Manager of the accident as soon as possible
> and appoint an SAIT liaison.
>
> H. Report any fire-related serious accident immediately to the
> Director, Office of Fire and Aviation.
>
> I. If an aircraft is involved, notify the Aviation Management
> Directorate, located in Boise, ID, as soon as possible.
>
> J. Immediately notify the HRO so that they can notify OWCP. (An
> autopsy/ toxicology report may or may not be required; OWCP must make
> this determination.)
>
> K. Notify the State Office of Public Affairs.
>
> L. If the deceased is an employee of another BLM office, another
> Federal agency, or a non‑Federal organization, establish and maintain
> communication with that office/organization to ensure the accurate and
> timely flow of information.
>
> M. Ensure staff assistants are instructed to route all incoming calls
> and visitors to the authorized
>
> spokesperson.
>
> N. Record all contacts and actions you have taken in the casualty log.

**Death as a Result of Illness,**

**Or Natural Causes** If an employee dies on the job as a result of
illness/natural causes, the RMO should:

> A. Obtain the specific information regarding the
>
> casualty (who, when, where, what, and how.)

B. Notify the State/Center Director and/or WO AD, the Servicing Human
Resources Office, State Safety Manager, and law enforcement officer.

C.  Appoint a Family Liaison. If the casualty is a law enforcement
    officer or a fire fighter, it is preferable that the family liaison
    be assigned from the same program area.

**7 NHRMC**

D. Using the Personal Emergency Information

> Card, identify the names of individuals who must be notified and
> notify the next-of-kin. If possible, the notification should be made
> in person by at least two people, one of whom knows the deceased or a
> family member.

**[SAFETY OFFICE]{.underline}**

**[OBJECTIVE]{.underline}** To ensure that every casualty is
investigated to establish primary and root cause(s) and other
contributing factors. To develop countermeasures based on investigative
findings and to prevent similar situations from occurring.

**[RESPONSIBILITIES]{.underline}** Normally the State/Center Safety
Manager will be notified by the RMO. However, if the RMO notifies a
designated representative in the field, that individual will have the
following responsibilities:

> A. Advise the first-level supervisor to secure the
>
> scene for an accurate investigation.
>
> B. Immediately notify the State Safety Manager. In
>
> addition, obtain copies of the casualty log to transmit to him/her.

Note: The Field representative does **[not]{.underline}** initiate the

> investigation.

**[PROCEDURES]{.underline}** The State/Center Safety Manager will:

> A. Advise the first-line supervisor to ensure the
>
> accident scene is secure in accordance with Appendix 1.
>
> B. Immediately notify the Bureau Safety Manager. Provide assistance as
> needed.

C.  Report the casualty within eight (8) hours to the nearest OSHA
    office.

D. If the responsibility is assigned to the State Safety Office,
immediately notify the DOL Office of Workers Compensation Program either
by telephone, fax or electronic mail. Submit to OWCP the Official

Superior's Report of Employee Death (CA-6)

**8 NHRMC**

> completed by the supervisor, along with a death certificate and a
> newspaper clipping if available.
>
> The death certificate must be sent as soon as it is available.

E. Immediately notify the appropriate DOI Solicitor's

> Office.
>
> Note: State/Center Safety Manager does not initiate the investigation.
> It is initiated by the Bureau Safety Manager.

The Bureau Safety Manager will:

> A. Advise the State/Center Safety Manager to ensure that the accident
> scene is secure.
>
> B. Assemble a Serious Accident Investigation Team
>
> (SAIT) in accordance with DM 485.7. Remain in
>
> contact with the investigation team to provide
>
> support as necessary.
>
> C. Notify the BLM and the Department DASHO, along with the DOI
> Managing Risk and Public Safety Office (MRPS).

**9 NHRMC**

**[LAW ENFORCEMENT OFFICE]{.underline}**

**[OBJECTIVE]{.underline}** To assist in the investigation of
accidents/incidents. If a BLM Ranger or Special Agent is killed, the RMO
will immediately notify the Special Agent-in-Charge, who will conduct
the investigation in accordance with Law Enforcement's General Orders.

**[PROCEDURES]{.underline}** The Law Enforcement Office will ensure that
the following

> is accomplished:
>
> A. If the casualty is a law enforcement officer:
>
> \(1\) Have the law enforcement staff serve as the lead in
> investigating the incident.
>
> \(2\) Appoint a law enforcement officer to the SAIT.
>
> \(3\) Notify the Chief, Law Enforcement, of the casualty and keep that
> office apprised of the status of the investigation of the incident,
> pursuant to *A Guide for Reporting Serious Law Enforcement Incidents*.
>
> \(4\) Coordinate with the Office of Public Affairs on the release of
> information about the incident.
>
> \(5\) Assist in the notification of next-of-kin and in providing
> support and assistance to family members.
>
> \(6\) Arrange for peer supporters to provide counseling services for
> employees who are affected by the accident/incident.

B.  For casualties that do not involve law enforcement personnel, one or
    more law enforcement officials may be designated to serve on the
    accident investigation team, as requested by the appropriate Safety
    Office.

> **10 NHRMC**

**[FAMILY LIAISON]{.underline}**

**[OBJECTIVE]{.underline}** To establish and maintain open lines of
communication between the BLM and the next‑of‑kin/survivors.

**[RESPONSIBILITIES]{.underline}** The RMO is responsible for the
following:

A.  When an employee casualty occurs, a Family

    Liaison must be appointed by the RMO to provide assistance to the
    survivor, beneficiary, or next‑of‑kin.

    B. When the casualty involves a fire or a law

    enforcement official, the family liaison should be

    from the same program area.

**[PROCEDURES]{.underline}**: The following specific procedures should
be accomplished by the Family Liaison if requested by the next-of-kin/
survivors and/or the RMO:

> A. Maintain a log of all contacts with the next of kin.
>
> B. Provide assistance with completing the paperwork needed to obtain
> benefits if requested or provide the name and telephone number of the
> contact in the Human Resources Office who can assist the next-of-kin
> in completing the paperwork.
>
> C. Gather the deceased employee's personal effects from the desk/work
> area. These personal effects should not be removed until any
> investigations are completed.
>
> D. Provide information to the workforce regarding funeral
> arrangements, memorial services, needs of the family, etc.
>
> E. Represent BLM at the funeral or memorial service, if possible.

**11 NHRMC**

**[HUMAN RESOURCES OFFICE]{.underline}**

**[OBJECTIVE]{.underline}** To assist management in ensuring that the
employee's beneficiaries are advised of the benefits to which they are
entitled.

**[PROCEDURES]{.underline}** The following are procedures which must be
completed by either the Field Support Services staff or the Human
Resources Office, depending on where the responsibility is delegated.

> A. Review the Official Personnel Folder (OPF) to determine who the
> survivors are, who is entitled to benefits, what the specific benefits
> are, and how benefits may be obtained.
>
> B. Immediately notify the Department of Labor (DOL) Office of Worker's
> Compensation Programs of the casualty by telephone, fax or electronic
> mail. Submit to OWCP the Official Superior's Report of Employee Death
> (Form CA-6) completed by the supervisor, along with a death
> certificate and a newspaper clipping, if available. The death
> certificate must be sent as soon as it is available.
>
> C. Prepare a letter of condolence for State/Center Director or WO AD
> signature. Refer to the sample provided in Appendix 6.
>
> D. Contact the Payroll Operations Office to obtain an estimated figure
> of unpaid compensation due to the survivor/beneficiary/next-of-kin.
> This information should be shared with the RMO.
>
> E. Provide assistance to the survivors, beneficiaries, or next‑of‑kin
> in completing claims for benefits if necessary. The Human Resources
> Office will review all forms for completeness prior to submitting them
> to appropriate Federal offices.
>
> F. Obtain from the next-of-kin/beneficiary sufficient certified copies
> (with raised seal) of the death certificate to accompany benefit
> claims. Copies are required for the following agencies, as applicable
> to the situation:
>
> **12 NHRMC**
>
> \(1\) DOL Office of Worker's Compensation Programs (OWCP) if
> appropriate.
>
> \(2\) Office of Personnel Management
>
> (OPM) to claim survivor benefits under the retirement system or the
> refund of retirement funds.
>
> \(3\) Office of Federal Employees Group Life Insurance.
>
> \(4\) Thrift Savings Plan.
>
> \(5\) Department of Defense (if employee was retired military).
>
> \(6\) Payroll Operations Office .
>
> \(7\) Department of Justice (if employee was performing law
> enforcement or firefighting duties and died in the line of duty).
>
> \(8\) Two or three additional copies for other life insurance
> policies, such as the Social Security Administration and the Veterans
> Administration if employee was a veteran.
>
> G. When and if appropriate, arrange for an Employee
>
> Assistance Program Counselor to come on-site to
>
> counsel employees. It is generally recommended
>
> that a counselor (peer, Critical Incident Stress
>
> Officer (CISO), EAP) be made available one or two
>
> days after the casualty occurrence, depending on the
>
> level of trauma involved.
>
> H. Provide to the deceased employee's survivor, beneficiary, or
> next-of-kin the \"employee\" copy of the Notification of Personnel
> Action, Standard Form 50 (SF‑50), along with a letter explaining that
>
> the SF-50 may be needed when submitting claims for benefits (See
> Appendix 7 for Sample.).

**13 NHRMC**

I.  Establish and maintain a case file of all relevant correspondence
    and information. At a minimum, the case file should include:

> \(1\) Copies of all OWCP claim forms, if appropriate.

\(2\) Copies of all benefit claim forms.

> \(3\) A copy of the death certificate.

\(4\) A copy of the SF‑50.

> \(5\) Copies of HRO correspondence to and from the
> survivors/next-of-kin/beneficiaries.

**14 NHRMC**

**[OFFICE OF PUBLIC AFFAIRS]{.underline}**

**[OBJECTIVE]{.underline}** To work closely with the supervisor/manager
to disseminate accurate and timely information to the public, press,
media, etc., and to coordinate the release of information to all
internal and external entities.

**[RESPONSIBILITIES]{.underline}** The following are some of the
responsibilities of the Public Affairs office if an employee casualty
occurs; however, this list is not all inclusive. Steps will vary
according to circumstances.

> A. Assist the RMO in developing a \"prepared statement\" of the facts
> surrounding the casualty for release to the media.
>
> B. Assure that the name(s) of deceased are not released until next of
> kin are notified.
>
> C. Issue regular internal and external information updates.
>
> D. Coordinate with the appropriate BLM Special Agent-in-Charge on the
> release of information in cases where the deceased is in a BLM law
> enforcement position.
>
> E. Submit an early alert of the casualty situation to the WO BLM
> Office of Public Affairs and provide them with periodic updates.

**15 NHRMC**

**[SURVIVOR BENEFITS]{.underline}**

**[Benefits vs. Type of Appointment]{.underline}**

The purpose of this section is to list the benefits that may be payable
to qualified survivors upon the death of a BLM employee. Benefits will
vary according to the type of appointment held and whether the death was
work related or resulted from natural causes that occurred on the job.
The type of employment status and the benefits that may be payable for
each are outlined below. Details of these benefits may be obtained from
the employee's Human Resources Office:

> **Career/Career Seasonal/Career Conditional/Term/SCEP Employees**:
> Employees whose work schedule may be full‑time, part‑time, or when
> actually employed (WAE).
>
> Office of Worker's Compensation Program (OWCP) Benefits

Civil Service Retirement System (CSRS) Benefits

Federal Employees Retirement System (FERS) Benefits

Thrift Savings Plan Benefits

Social Security (Old‑Age, Survivors and Disability Insurance (OASDI))
Benefits

Federal Employees Group Life Insurance (FEGLI) Benefits

Federal Employees Health Benefits (FEHB)

Unpaid Compensation (leave, travel, last paycheck)

Public Safety Officers (PSO) Benefits

Veterans Benefits

> **STEP Employees**: Federal Employee's Health Benefits (FEHB) after
> one year of employment.
>
> **Temporary Employees**: Non permanent employees who normally work
> less than twelve (12) months at a time on a full‑time, part‑time,
> seasonal, or intermittent basis:
>
> OWCP Benefits OASDI Benefits
>
> Unpaid Compensation PSO Benefits
>
> Death Gratuity Veterans Benefits
>
> **Volunteers**: Persons who formally apply for and are accepted to
> work without compensation. A volunteer may work part‑time or
> full‑time, or on a one-time service project.

OWCP Benefits

PSO Benefits

Veterans Benefits

**16 NHRMC**

**APPENDICES**

Form 1400-113 UNITED STATES Appendix 1

(June 2000) DEPARTMENT OF THE INTERIOR

BUREAU OF LAND MANAGEMENT

**CASUALTY LOG**

Record all information/action taken in relation to this casualty.

**[Personal Information:]{.underline}**

Full Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date/Time
occurred: \_\_\_/\_\_\_/\_\_\_ \_\_\_:\_\_\_\_\_ am pm

Age: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Home address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Duty location: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Next-of-kin: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Relationship:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact number: ( ) \_\_\_\_\_ - \_\_\_\_\_\_\_

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**[Incident/Accident Information:]{.underline}**

What happened:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Where:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Site secured: Yes \_\_\_\_ No \_\_\_\_ Date \_\_\_/\_\_\_/\_\_\_
Responsible Party \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  --------------------------- --------------- --------- -------- ---------- -------------------
  **[List of personnel                                                      
  contacted:]{.underline} -                                                 
  [Do]{.underline}                                                          
  [Not]{.underline} call                                                    
  employees's spouse or                                                     
  next-of-kin - this done by                                                
  RMO**                                                                     

                              **Name**        **Yes**   **No**   **Date**   **Responsible
                                                                            Party**

  **Field Manager**                                                         

  **Safety**                                                                

  **LE**                                                                    

  **Fire**                                                                  

  **Public Affairs Office**                                                 

  **SPO**                                                                   
  --------------------------- --------------- --------- -------- ---------- -------------------

Was next-of-kin notified: Yes \_\_\_ No \_\_\_ Date/Time
\_\_\_/\_\_\_/\_\_\_ \_\_\_\_:\_\_\_\_\_\_ am pm

Responsible Party
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Family Liaison appointed:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Continued on reverse)*

Additional contacts/actions:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Appendix 2

+---------------+-------------------------------+----------------------+
| Form          | U.S. DEPARTMENT OF THE        | Date of the card     |
| 1400-71(296)  | INTERIOR                      |                      |
|               |                               |                      |
| (June 1988)   | BUREAU OF LAND MANAGEMENT     |                      |
|               |                               |                      |
|               | **PERSONAL EMERGENCY          |                      |
|               | INFORMATION CARD**            |                      |
+---------------+-------------------------------+----------------------+

  ------------------ ------------------------------- ---------------------
  Employee Name      Home Address (*include zip      Home Phone\*
  (*last, first,     code)*                          
  middle initial)*                                   

  ------------------ ------------------------------- ---------------------

  ------------------ ----------- ------------------- ---------------------
  NAME               RELATION    ADDRESS (include    PHONE\*
                                 zip code)           

  1\.                                                

  2\.                                                

  3\.                                                
  ------------------ ----------- ------------------- ---------------------

  -----------------------------------------------------------------------
  FAMILY DOCTOR(S)

  -----------------------------------------------------------------------

  ------------------ ------------------------------- ---------------------
  NAME               ADDRESS (include zip code)      OFFICE PHONE\*

  1\.                                                

  2\.                                                

  3\.                                                
  ------------------ ------------------------------- ---------------------

+-----------------------------------------------------------------------+
| (*Continued on reverse) \*Include area code*                          |
|                                                                       |
| ![](media/image3.wmf){width="0.19305555555555556in"                   |
| height="0.18333333333333332in"}                                       |
|                                                                       |
| ![](media/image3.wmf){width="0.19305555555555556in"                   |
| height="0.18333333333333332in"}                                       |
|                                                                       |
| Are you covered under a health benefit plan? Yes No If yes, name of   |
| the plan:                                                             |
+-----------------------------------------------------------------------+

  -------------------------- --------------------------------------------
  Enrollment code:           Hospital preference:

  Blood type:                Allergies:
  -------------------------- --------------------------------------------

+-----------------------------------------------------------------------+
| Handicap(s):                                                          |
+-----------------------------------------------------------------------+
| Medication(s) you are required to take daily:                         |
+-----------------------------------------------------------------------+
| Medical Alert Conditions which should be known in an emergency:       |
+-----------------------------------------------------------------------+
| Special Instructions:                                                 |
+-----------------------------------------------------------------------+
| NOTICE                                                                |
|                                                                       |
| This information is being collected pursuant to Title 5 U.S.C.        |
| Section 7901, which provides for the establishment of procedures to   |
| deal with emergency situations.                                       |
|                                                                       |
| The information in this record card will be used only in an emergency |
| to speed the provision of medical care and/or to notify a relative(s) |
| or other person(s)                                                    |
|                                                                       |
| Specified of an accident or injury. This record card will not be used |
| for any other purposes. The disclosure of this information is         |
| strictly voluntary and there will                                     |
|                                                                       |
| not be any adverse effects on your employment status if you do not    |
| complete this record care.                                            |
+-----------------------------------------------------------------------+

\*U.S. Government Printing Office: 1993 -- 774-017/67087

Appendix 3

+-------------------------------------+--------------------------------+
| **Official Superior's Report of**   | ## U.S. Department of Labor    |
|                                     |                                |
| **Employee's Death**                | Employment Standards           |
|                                     | Administration                 |
|                                     |                                |
|                                     | Office of Worker's             |
|                                     | Compensation Programs          |
+-------------------------------------+--------------------------------+

+--------------------------+-------------------+-------+-------------+
| 1\. Name of Deceased     | 2\. Date of Birth | 3\.   | 4\. Social  |
| Employee (Last, first,   | (Mo., day, year)  |       | Security    |
| middle)                  |                   | Male  | No.         |
|                          |                   |       |             |
|                          |                   | F     |             |
|                          |                   | emale |             |
+--------------------------+-------------------+-------+-------------+

  -------------------------------- -------------------- -----------------
  5\. Department or Agency         6\. OWCP Agency Code 7\. OSHA Site
                                                        Code

  -------------------------------- -------------------- -----------------

  -------------------------------- --------------------------------------
  8\. Name and Address of          Name and Office Phone Number of
  Reporting Office                 Employee's Official Superior

  -------------------------------- --------------------------------------

+-----------------------+------------------+---------------------------+
| 10\. Date and Hour of | 11\. Date and    | 12\. Date and Hour        |
| Injury                | Hour of Death    | Employee's Pay Stopped    |
|                       |                  |                           |
| (Mo., day, year)      | (Mo., day, year) | (Mo., day, year)          |
|                       |                  |                           |
| AM                    | AM               | AM                        |
|                       |                  |                           |
| PM                    | PM               | PM                        |
+-----------------------+------------------+---------------------------+

+--------------------------------+-------------------------------------+
| 13\. Describe how injury       | 14\. Was employee in performance of |
| occurred                       | duty when injury occurred?          |
|                                |                                     |
|                                | Yes No (if No, explain):            |
+--------------------------------+-------------------------------------+

+-----------------------+------------------+---------------------------+
| 15\. Location where   | 16\. Location    | 17\. Immediate cause of   |
| injury occurred       | where death      | death (Attach medical     |
|                       | occurred         |                           |
|                       |                  | and autopsy report if     |
|                       |                  | available)                |
+-----------------------+------------------+---------------------------+

+------------------------+------------+---------+---------+-----------+
| 18\. Employee's pay    | a\. Base   | b\.     | c\.     | d\. Other |
| rate as of             | pay        | Subs    | Q       |           |
|                        |            | istence | uarters | \$ per    |
| A. Date of injury      | \$ per     |         |         |           |
|                        |            | \$ per  | \$ per  | \$ per    |
| B. Date pay stopped    | \$ per     |         |         |           |
|                        |            | \$ per  | \$ Per  |           |
+------------------------+------------+---------+---------+-----------+

+-----------------------------------+----------------------------------+
| 19\. Did employee work in         | 20\. If answer to 19 is no,      |
| position held at time of injury   | would position have afforded     |
| for a                             | employment                       |
|                                   |                                  |
| full eleven months immediately    | for eleven months except for the |
| prior to the injury?              | injury?                          |
|                                   |                                  |
| yes no                            | yes no                           |
+-----------------------------------+----------------------------------+

+-------------------------------------------+--------------------------+
| 21 Did employee receive leave pay for any | 22\. a. Occupation code  |
| part of period from time pay stopped to   |                          |
|                                           |                          |
| date of death? (Give inclusive dates)     |                          |
|                                           |                          |
| From To                                   |                          |
+-------------------------------------------+--------------------------+

  -------------------------------------------- --------------- -----------
                                               b\. Type code   c\. Source
                                                               code

  -------------------------------------------- --------------- -----------

+-------------------------------------------+--------------------------+
|                                           | OWCP use -- NOI code     |
+-------------------------------------------+--------------------------+
| 23 Did employee receive continuation of   | 24\. If employee was     |
| pay (COP) during period prior to death?   | enrolled in Health       |
|                                           |                          |
|                                           | Benefit Plan for self    |
|                                           | and family, show HBS     |
|                                           | Code                     |
|                                           |                          |
|                                           | Number                   |
+-------------------------------------------+--------------------------+

+--------------------+----------------------+--------------------------+
| a\. Pay rate used  | b\. Inclusive dates  |                          |
| for COP            | of COP               |                          |
|                    |                      |                          |
| \$ per             | From TO              |                          |
+--------------------+----------------------+--------------------------+

+----------------------+---------------------------+------------------+
| 25\. Show date       | 26\. Identify employee's  | 27\. If employee |
| through which HBS    | Federal Retirement Plan:  | received medical |
| deductions           |                           | care             |
|                      | CSBS FERS Other           |                  |
| were last made (Mo., | \_\_\_\_\_\_\_\_\         | prior to death,  |
| day, year)           | _\_\_\_\_\_\_\_\_\_\_\_\_ | give name and    |
|                      |                           |                  |
|                      |                           | address of       |
|                      |                           | attending        |
|                      |                           | physician.       |
+----------------------+---------------------------+------------------+
| 28\. If injury was   | 29\. Give name and        | **30. Show       |
| caused by a third    | address of the attorney   | amount of        |
| party, give          | representing the          | third**          |
|                      |                           |                  |
| name and address of  | survivors if legal action | **party recover, |
| third party          | is instituted against the | if any**         |
|                      | third party               |                  |
|                      |                           | **\$**           |
+----------------------+---------------------------+------------------+

+-------------------------------------+--------------------------------+
| 31\. If employee was a member of    | 32\. Has claim for survivor's  |
| the Armed Services in the United    | benefits been filed with the   |
| States show:                        |                                |
|                                     | Office of Personnel            |
| Branch of Service:                  | Management?                    |
|                                     |                                |
| Serial No. (If known)               | Yes No                         |
+-------------------------------------+--------------------------------+

  -----------------------------------------------------------------------
  33\. Name and address of employee's spouse or next of kin (Show
  relationship, if other than spouse)

  -----------------------------------------------------------------------

  ----------------------------------- ---------------------- -------------
  34\. Signature of Official Superior 35\. Title             36\. Date
                                                             (Mo., day,
                                                             year)

  ----------------------------------- ---------------------- -------------

Form CA-6

Form 1340-2 UNITED STATED DEPARTMENT OF THE INTERIOR

(January 2004) Bureau of Land Management

# FINAL SALARY CLEARANCE REPORT

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 15%" />
<col style="width: 20%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 14%" />
<col style="width: 22%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="21">Instructions: <strong>This form should be completed 72
hours in advance of your termination date.</strong> Since you are
separating from the BLM, you must return all of the items listed below
which are in your possession before separation. Please hand carry this
form to the offices listed below with the exception of the Finance
Office. Turn in the office materials, equipment, property etc. which
have been assigned to you. Please ensure that the responsible official
in each office signs the form in the appropriate spot. All blocks must
be initialed as either “OK” meaning the items have been cleared or “N/A”
as Not applicable. <strong><u>THE COMPLETED FORM WILL BE FILED AT THE
BLM-BC, BC-620.</u></strong></td>
</tr>
<tr class="even">
<td colspan="6">Name of employee</td>
<td colspan="7">Social Security Number</td>
<td colspan="8">Office Code</td>
</tr>
<tr class="odd">
<td colspan="3">Last Day of Active Duty</td>
<td colspan="18"><p>Indicate one of the following actions: Resigning
Retiring</p>
<p>Other, Within DOI BLM Transfer (specify BLM Office) Other, Outside
DOI □ Other</p></td>
</tr>
<tr class="even">
<td><strong>Item</strong></td>
<td colspan="6"><strong>Immediate Office/Supervisor</strong></td>
<td colspan="3"><p><strong>Initial</strong></p>
<p><strong>OK N/A</strong></p></td>
<td colspan="2"><h2 id="item">Item</h2></td>
<td colspan="2"><h2 id="information-technology">Information
Technology</h2></td>
<td colspan="7"><h2 id="initial">Initial</h2>
<p><strong>OK N/A</strong></p></td>
</tr>
<tr class="odd">
<td>1</td>
<td colspan="6">Accountable Property Returned with completed DI-105</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">28</td>
<td colspan="2">Electronic Mail Cleared/ Lotus Notes Updated</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td>2</td>
<td colspan="6">Non-Accountable Property Returned, i.e. field gear</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">29</td>
<td colspan="2">Electronic Files Transferred</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td>3</td>
<td colspan="6">Desk Keys</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">30</td>
<td colspan="2">Telecommunications- Calling Card, Cellular Phone, Pager,
and Two-Way Radio</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="6">Outstanding Travel Vouchers/Bills</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">31</td>
<td colspan="2">Voice Mail Password</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="6">Time/Attendance Report Input and Submitted</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">32</td>
<td colspan="2">Government Emergency Telecommunications Service
Cards</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td rowspan="2">6</td>
<td colspan="6" rowspan="2"><p>Charge Card Balance Reviewed in
Coordination With</p>
<p>Local A/OPC</p></td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2"></td>
<td colspan="2">33</td>
<td colspan="2">IT Security- Login Access Request</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2">34</td>
<td colspan="2">Other</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td>7</td>
<td colspan="6">Travel/Purchase Charge Card Statement on file for three
(3) years</td>
<td></td>
<td colspan="2"></td>
<td colspan="11" rowspan="3"><p><u>_____</u></p>
<p>Signature, IT Security Date</p></td>
</tr>
<tr class="odd">
<td>8</td>
<td colspan="6">Official Passports/Visas</td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9</td>
<td colspan="6">Secretarial I.D. Cards</td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>10</td>
<td colspan="6">Federal Emergency Management I.D. Card</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"><strong>Item</strong></td>
<td colspan="2"><h2 id="library">Library</h2></td>
<td colspan="7"><p><strong>Initial</strong></p>
<p><strong>OK N/A</strong></p></td>
</tr>
<tr class="even">
<td>11</td>
<td colspan="6">Security Clearance Debriefing Form</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">35</td>
<td colspan="2">Library Materials Turned In</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td>12</td>
<td colspan="6">Removed from PayCheck System at End of Pay Period</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">36</td>
<td colspan="2">Other</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="2">13</td>
<td colspan="5">Other</td>
<td></td>
<td colspan="2"></td>
<td colspan="11" rowspan="2"><p><u>_____</u></p>
<p>Signature, Librarian Date</p></td>
</tr>
<tr class="odd">
<td colspan="10">Signature, Employee’s Supervisor Date</td>
</tr>
<tr class="even">
<td><strong>Item</strong></td>
<td colspan="3"><strong>Office Services</strong></td>
<td colspan="6"><p><strong>Initial</strong></p>
<p><strong>OK N/A</strong></p></td>
<td colspan="2"><strong>Item</strong></td>
<td colspan="3"><strong>Charge Card Coordinator (A/OPC)</strong></td>
<td colspan="6"><p><strong>Initial</strong></p>
<p><strong>OK N/A</strong></p></td>
</tr>
<tr class="odd">
<td>14</td>
<td colspan="3">BLM Issued Identification Card</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2">37</td>
<td colspan="3">Charge Card Destroyed/Cancelled</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>15</td>
<td colspan="3">Office Keys</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2">38</td>
<td colspan="3">Account Transferred to Receiving BLM Office</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>16</td>
<td colspan="3">Parking Permit</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2">39</td>
<td colspan="3">Uniform Draw Down Card, Returned and Canceled</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>17</td>
<td colspan="3">Government Driver’s License</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2">40</td>
<td colspan="3">Other</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td>18</td>
<td colspan="3">Building Access Cards</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="11" rowspan="2"><p><u>_____</u></p>
<p>Signature, Charge Card Coordinator Date</p></td>
</tr>
<tr class="even">
<td>19</td>
<td colspan="3">Other</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="10" rowspan="3"><p><u>____</u></p>
<p>Signature, Admin Support Officer Date</p></td>
<td><strong>Item</strong></td>
<td colspan="6"><strong>Finance Office (BLM-BC)</strong></td>
<td colspan="4"><p><strong>Initial</strong></p>
<p><strong>OK N/A</strong></p></td>
</tr>
<tr class="even">
<td>41</td>
<td colspan="6">Travel Advances</td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td>42</td>
<td colspan="6">Outstanding Bills (BC-621)</td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="3"><strong>Item</strong></td>
<td colspan="3" rowspan="3"><strong>Human Resources Office</strong></td>
<td colspan="6" rowspan="3"><p><strong>Initial</strong></p>
<p><strong>OK N/A</strong></p></td>
<td rowspan="3">43</td>
<td colspan="5">FFS</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="5">IDEAS</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="5">CBS</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td>20</td>
<td colspan="3">SF-52 Signed/ Dated with Forwarding Address</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td>44</td>
<td colspan="5">Other</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td>21</td>
<td colspan="3">Leave/Final Salary</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="11" rowspan="3"><p><u>_____</u></p>
<p>Signature, Finance Officer Date</p></td>
</tr>
<tr class="odd">
<td>22</td>
<td colspan="3">FEHB/FEGLI</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>23</td>
<td colspan="3">Retirement/TSP</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>24</td>
<td colspan="3">Exit Interview</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="11" rowspan="5"><p>Notes: See # _____ Above:
<u>______________________________________</u></p>
<p><u>_____________________________________________________________</u></p>
<p><u>_____________________________________________________________</u></p>
<p><u>_____________________________________________________________</u></p>
<p>See #_____ Above:________________________________________________</p>
<p>_____________________________________________________________________________________________________________________________________________________________________________________________</p></td>
</tr>
<tr class="even">
<td>25</td>
<td colspan="3">FPPS</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">26</td>
<td colspan="2">Transit Benefit Program</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">27</td>
<td colspan="3">Other</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10" rowspan="4"><p>These items have been discussed with the
employee. Information has been provided as appropriate.</p>
<p>­­­­­­­­­­­­­­­­­­­­­­­­­­</p>
<p>Signature, Human Resources Representative Date</p></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="11"><h2
id="see-_____-above_______________________________________________">See
#_____ Above:_______________________________________________</h2>
<p>______________________________________________________________________________________________________</p></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
</tbody>
</table>

[SPECIFIC INSTRUCTIONS FOR ACCOUNTABLE OFFICES]{.underline}

[EMPLOYEE'S IMMEDIATE SUPERVISOR.]{.underline} The Final Salary
Clearance Form is required for all separating employees before final
salary and/or lump sum payments are processed. The Employee's immediate
supervisor is responsible for ensuring that the employee processes out
prior to leaving the BLM. In addition, if the employee is charged with
lost property or equipment subject to monetary deductions, a copy of the
Board of Survey report or action should be attached. If the Board's
report is not available at the time of the employee's separation, its
unavailability and the date by which the report will be provided should
be annotated on the Salary Clearance Sheet. Once the employee has
cleared, the Final Salary Clearance Sheet will be returned to the BLM
Business Center's Accounting Operations Division (BC-620).

[ALL OTHER ACCOUNTABLE OFFICES (Property, Human Resources, Finance,
Information Technology).]{.underline} When the separating employee
clears with your office, please obtain the property or materials for
which you are responsible, initial each item, and for your section, date
and sign your name certifying that the employee has cleared with your
area.

![](media/image4.png){width="7.625in"
height="9.872222222222222in"}![](media/image5.png){width="7.626388888888889in"
height="9.998611111111112in"}![](media/image6.png){width="7.622916666666667in"
height="9.998611111111112in"}![](media/image7.png){width="7.622916666666667in"
height="9.998611111111112in"}![](media/image8.png){width="7.624305555555556in"
height="9.997222222222222in"}![](media/image9.png){width="7.625in"
height="10.0in"}

Appendix 6

1400-xxx (HR-220)

Addressed to Survivor/Beneficiary

Dear *name:*

I wish to express my sympathy concerning the loss of your
(husband/wife/father, etc.). *(Name)* was a valued employee while
working for (*name of division)* with the Bureau of Land Management.
(*Enter a short description describing the deceased accomplishments or
if appropriate, description of a particularly noteworthy occasion. This
information should come from, and be provided by deceased employee's
supervisor.)*

(*First name)* will be missed by *(his/her)* co-workers, supervisors,
and managers within the Bureau of Land Management, both personally and
professionally.

I have asked \_\_\_\_\_\_\_\_\_\_\_\_\_ to be available should you be in
need of assistance or have any questions that you would like to ask with
regard to your *(husband's/wife's/son's/etc.)* benefits. *(His/her)*
telephone number is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

With Sympathy,

*State Director*

> Appendix 7

1400-xxx (HR-220)

Addressed to Survivor/Beneficiary

Dear *name:*

Please accept our condolences for the loss of your *[describe
relationship, i.e., spouse.]{.underline}*

Enclosed is a copy of the Notification of Personnel Action (SF-50B).
This document may be needed when you apply for the various benefits to
which you are entitled. We recommend that you retain a copy of this
document in your files as you may need it at some future date.

If you have questions with regard to this document or are in need of
assistance, please call \_\_\_\_\_\_\_\_\_\_\_\_\_\_ at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Sincerely,

*Personnel Officer*

1 Enclosure

1 - Notification of Personnel Action (SF-50B)

Appendix 8

**LISTING OF POTENTIALLY INVOLVED FEDERAL AGENCIES**

**[Bureau of Land Management]{.underline}**

**Bureau Safety Manager**

**Office: 202-501-2664**

**Cell: 202-557-4466**

**In the event the Bureau Safety Manager is not available, call the BLM
Safety Manager's Staff Assistant**

**Office: 202-501-2622**

**[Aviation Management Directorate (AMD)]{.underline}**

**AMD Main Office phone number**

**(208) 433-5002**

300 East Mallard Drive, Suite 200

Boise, Idaho 83706-3991

**[Office of Workers Compensation]{.underline}**

**http://www.dol.gov/esa/regs/compliance/owcp/fecacont.htm**

**Regional Phone numbers -**

> 1\. **District Office 12 - Denver**
>
> **(Colorado, Montana, No. Dakota, So. Dakota, Utah and**
>
> **Wyoming)**
>
> **(720) 264-3000**
>
> **FAX: (720) 264-3046**
>
> U.S. Department of Labor, OWCP
>
> 1999 Broadway, Suite 600
>
> Denver, CO 80202
>
> 2\. **District Office 13 -- San Francisco**
>
> **(Arizona, California, Hawaii, and Nevada)**
>
> **(415) 848-6700l**
>
> **FAX: (415) 848-6800**

U.S. Dept. Of Labor, OWCP

71 Stevenson Street, Suite 305

San Francisco, CA 94105

Or write to:

P.O. Box 3769

San Francisco, CA 94119-3769

Appendix 8-2

3\. **District Office 14 -- Seattle**

**(Alaska, Idaho, Oregon, and Washington)**

**(206) 398-8100**

**FAX: (206) 398-8151**

U.S. Dept. Of Labor, OWCP

1111 Third Avenue, Suite 650

Seattle, WA 98101-3212

4\. **District Office 16 -- Dallas**

**(Arkansas, Louisiana, New Mexico, Oklahoma, Texas)**

**(972) 850-2300**

**FAX: (972) 850-2301**

U.S. Department Of Labor, OWCP

525 South Griffin Street, Room 100

Dallas, TX 75202

5\. **District Office 25 -- Washington, D.C.**

**(District of Columbia, Maryland, and Virginia)**

**(202) 513-6800**

**FAX: (202) 513-6806**

U.S. Dept. Of Labor, OWCP

800 N. Capitol Street, NW, Room 800

Washington, D.C. 20211

**[Occupational Safety and Health Administration (OSHA)]{.underline}**

**http://www.osha.gov**

> To report a fatality call 1-800-321-OSHA (6742)

as soon as possible and no later than eight hours after the death.

Ref. OSHA 29 CFR 1960.70.

**[Social Security Administration]{.underline}**

**Information about claims 1-800-772-1213**

**http://www.socialsecurity.gov**

**[Employee Assistance Program Public Health Service]{.underline}**

**Please fill in EAP local phone number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**