U.S. Department of Labor 

Office of Workers' Compensation Programs

Federal Employee's Notice of Traumatic Injury and 

Claim for Continuation of Pay/Compensation

Employee: Please complete all boxes 1 - 15 below. Do not complete shaded areas. 

Witness: Complete bottom section 16. 

Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.

Employee Data

1. Name of employee (Last, First, Middle) 2. Social Security Number

3. Date of birth Mo. Day Yr. 5. Home telephone 6. Grade as of 

 date of injury Level Step

7. Employee's home mailing address (include street address, city, state, and ZIP code)

City State ZIP Code

8. Dependents

Wife, Husband

Children under 18 years

Other

Description of Injury

9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)

10. Date injury occurred

Mo. Day Yr.

Time

a.m.

p.m.

11. Date of this notice

Mo. Day Yr.

12. Employee's occupation

13. Cause of injury (Describe what happened and why)

14. Nature of injury (identify both the injury and the part of the body, e.g., fracture of left leg) a. Occupation code

b. Type code c. Source code

OWCP Use - NOI Code

Employee Signature

15. I certify, under penalty of law, that the injury described above was sustained in performance of duty as an employee of the United States 

 Government and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication. I hereby 

 claim medical treatment, if needed, and the following, as checked below, while disabled for work: 

a. Continuation of regular pay (COP) not to exceed 45 days and compensation for wage loss if disability for work continues beyond 45 days. 

 If my claim is denied, I understand that the continuation of my regular pay shall be charged to sick or annual leave, or be deemed an 

 overpayment within the meaning of 5 USC 5584.

b. Sick and/or Annual Leave

I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information 

to the U.S. Department of Labor, Office of Worker's Compensation Program (or to its official representative). This authorization also permits any 

official representative of the Office to examine and to copy any records concerning me.

Signature of employee or person acting on his/her behalf Date

Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation 

as provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies 

as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.

Have your supervisor complete this receipt attached to this form and return it to you for your records.

Witness Statement

16. Statement of witness (Describe what you saw, heard, or know about this injury)

Name of witness Signature of witness Date signed

Address City State ZIP Code

Form CA-1 

Revised October 2018

1a. Email address

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or 

modifications, please contact OWCP.

4. Gender 
Official Supervisor's Report: Please complete information requested below:

Supervisor's Report

17. Agency name and address of reporting office (include street address, city, state, and ZIP code) OWCP Agency Code

OSHA Site Code

City State ZIP Code

18. Employee's duty station (include street address, city, state and ZIP code) City State ZIP Code

19. Employee's retirement coverage CSRS FERS Other, (identify)

20. Regular 

 work 

 hours

From:

a.m.

p.m.

To:

a.m.

p.m.

21. Regular 

 work 

 schedule

Sun. Mon. Tues. Wed. Thurs. Fri. Sat.

22. Date of Injury

Mo. Day Yr.

23. Date notice received

Mo. Day Yr.

24. Date stopped work

Mo. Day Yr. Time:

a.m.

p.m.

25. Date pay stopped

Mo. Day Yr.

26. Date 45 day period began

Mo. Day Yr.

27. Date returned to work

Mo. Day Yr. Time:

a.m.

p.m.

28. Was employee injured in performance of duty? Yes No (If "No," explain)

29. Was injury caused by employee's willful misconduct, intoxication, or intent to injure self or another? Yes (If "Yes," explain) No

30. Was injury caused by third party?

Yes No (If "No," go 

to Item 32,)

31. Name and address of third party (include street address, city, state, and ZIP code)

City State ZIP Code

32. Name and address of physician first providing medical care (include street address, city, state, ZIP code)

City State ZIP Code

33. First date medical 

 care received

Mo. Day Yr.

34. Do medical reports 

 show employee is 

 disabled for work?

Yes No

35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses? Yes No (If "No," explain)

36. If the employing agency controverts continuation of pay, state the reason in detail. 37. Pay rate when employee stopped work

Per

Signature of Supervisor and Filing Instructions

38. A supervisor who knowingly certifies to any false statement, misrepresentation concealment of fact, etc. in respect of this claim may also be 

 subject to appropriate felony criminal prosecution.

I certify that the information given above and that furnished by the employee on the reverse of this form is true to the best of my knowledge 

with the following exception:

Name of supervisor (Type or print)

Signature of supervisor Date

Supervisor's Title Office phone

39. Filing instructions No lost time and no medical expense: Place this form in employee's medical folder (SF-66-D)

No lost time, medical expense incurred or expected: forward this form to OWCP

Lost time covered by leave, LWOP, or COP: forward this form to OWCP

First Aid Injury

Form CA-1 

Revised October 2018 

Page 2
Instructions for Completing Form CA-1

Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental 

statement to the form. Some of the items on the form which may require further clarification are explained below.

Employee (or person acting on the employees' behalf)

13) Cause of injury

Describe in detail how and why the injury occurred. Give 

appropriate details (e.g.: If you fell, how far did you fall and in 

what position did you land?)

14) Nature of injury

Give a complete description of the condition(s) resulting from 

your injury. Specify the right or left side if applicable (e.g., 

fractured left leg: cut on right index finger).

15) Election of COP/Leave

If you are disabled for work as a result of this injury and filed 

CA-1 within thirty days of the injury, you may be entitled to receive 

continuation of pay (COP) from your employing agency. COP is 

paid for up to 45 calendar days of disability, and is not charged 

against sick or annual leave. If you elect sick or annual leave 

you may not claim compensation to repurchase leave used 

during the 45 days of COP entitlement.

Supervisor

As the time the form is received, complete the receipt of notice of 

injury and give it to the employee. In addition to completing 

Items 17 through 39, the supervisor is responsible for obtaining 

the witness statement in Item 16 and for filling in the proper codes 

in shaded boxes a, b, and c on the front of the form. If medical 

expense or lost time is incurred or expected, the completed form 

should be sent to OWCP within 10 working days after is received.

The supervisor should also submit any other information or 

evidence pertinent to the merits of this claim. 

If the employing agency controverts COP, the employee should 

be notified and the reason for controversion explained to him or 

her.

17) Agency name and address of reporting office

The name and address of the office to which correspondence 

from OWCP should be sent (if applicable, the address of the 

personnel or compensation office).

18) Duty station street address and zip code

The address and zip code of the establishment where the 

employee actually works.

19) Employers Retirement Coverage.

Indicate which retirement system the employee is covered under.

30) Was injury caused by third party?

A third party is an individual or organization (other than the 

injured employee or the Federal government) who is liable for 

the injury. For instance, the driver of a vehicle causing an 

accident in which an employee is injured, the owner of a 

building where unsafe conditions cause an employee to fall, and 

a manufacturer whose defective product causes an employee's 

injury, could all be considered third parties to the injury.

32) Name and address of physician first providing medical 

care

The name and address of the physician who first provided 

medical care for this injury. If initial care was given by a nurse 

or other health professional (not a physician) in the employing 

agency's health unit or clinic, indicate this on a separate sheet 

of paper.

33) First date medical care received

The date of the first visit to the physician listed in Item 31.

36) If the employing agency controverts continuation of 

 pay, state the reason in detail.

COP may be controverted (disputed) for any reason; however, 

the employing agency may refuse to pay COP only if the 

controversion is based upon one of the nine reasons given 

below: 

a) The disability was not caused by a traumatic injury. 

b) The employee is a volunteer working without pay or for 

 nominal pay, or a member of the office staff of a former 

 President; 

c) The employee is not a citizen or a resident of the United 

 States or Canada; 

d) The injury occurred off the employing agency's premises and 

 the employee was not involved in official "off premise" duties; 

e) The injury was proximately caused by the employee's willful 

 misconduct, intent to bring about injury or death to self or 

 another person, or intoxication; 

f) The injury was not reported on Form CA-1 within 30 days 

 following the injury; 

g) Work stoppage first occurred 45 days or more following 

 the injury; 

h) The employee initially reported the injury after his or her 

 employment was terminated; or 

i) The employee is enrolled in the Civil Air Patrol, Peace Corps, 

 Youth Conservation Corps, Work Study Programs, or other 

 similar groups.

Form CA-1 

Revised October 2018 

Page 3

Injured workers should provide an email address when completing 

this form. Pursuant to policy established by the Department of Labor, 

Office of Workers' Compensation Programs (OWCP), Division of 

Federal Employees' Compensation, email communication on case 

specific inquiries is not allowed due to security concerns. However, 

obtaining claimant email addresses at the point of filing will allow 

OWCP to share general, non-case specific information with injured 

workers earlier in the claims submission process. As a longstanding 

policy and in an effort to protect the identities and personal 

information of claimants under the Federal Employees' 

Compensation Act, and to allow better tracking of incoming 

communications, we do not use two-way email as a primary method 

of interaction with claimants and their representatives.)

1a) Email address
Benefits for Employees under the Federal Employees' Compensation Act (FECA)

The FECA, which is administered by the Office of Workers' 

Compensation Programs (OWCP), provides the following 

benefits for job-related traumatic injuries:

(1) Continuation of pay for disability resulting from traumatic, 

 job-related injury, not to exceed 45 calendar days. (To be 

 eligible for continuation of pay, the employee, or someone 

 acting on his/her behalf, must file Form CA-1 within 30 days 

 following the injury and provide medical evidence in support 

 of disability within 10 days of submission of the CA-1. Where 

 the employing agency continue's the employee's pay, the pay 

 must not be interrupted unless one of the provision's outlined 

 in 20 CFR 10.222 apply.

(2) Payment of compensation for wage loss after the expiration 

 of COP, if disability extends beyond such point, or if COP is not 

 payable. If disability continues after COP expires, Form CA-7, 

 with supporting medical evidence, must be filed with OWCP. 

 To avoid interruption of income, the form should be filed on the 

 40th day of the COP period.

(3) Payment of compensation for permanent impairment of 

 certain organs, members, or functions of the body (such as 

 loss or loss of use of an arm or kidney, loss of vision, etc.), 

 or for serious defringement of the head, face, or neck.

(4) Vocational rehabilitation and related services where 

 directed by OWCP.

(5) All necessary medical care from qualified medical providers. 

 The injured employee may choose the physician who provides 

 initial medical care. Generally, 25 miles from the place of 

 injury, place of employment, or employee's home is a 

 reasonable distance to travel for medical care.

An employee may use sick or annual leave rather than LWOP 

while disabled. The employee may repurchase leave used 

for approved periods. Form CA-7b, available from the 

personnel office, should be studied BEFORE a decision 

is made to use leave.

For additional information, review the regulations governing 

the administration of the FECA (Code of Federal Regulations, 

Chapter 20, Part 10) or pamphlet CA-810.

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' 

Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation 

Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. 

(2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be 

verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the 

claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to 

consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other 

government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and 

services. (5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational 

rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may 

be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to 

determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to 

pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. 

(7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or 

TIN), and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the 

Federal government, and for other purposes required or authorized by law. (8) Failure to disclosure all requested information may delay the 

processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. 

Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the 

processing and adjudication of the claim you filed under the FECA.

Receipt of Notice of Injury

This acknowledges receipt of Notice of Injury sustained by (Name of injured employee)

Which occurred on (Mo. Day, Yr.)

At (Location)

Signature of Official Superior Title Date (Mo. Day, Yr.)

*U.S. GPO: 1999-454-845/12704

Form CA-1 

Revised October 2018 

Page 4

Instructions for Completing Form CA-1 Continued

Employing Agency - Required Codes

Box a (Occupation Code), Box b (Type Code), 

Box c (Source Code), OSHA Site Code

The Occupational Safety and Health Administration (OSHA) 

requires all employing agencies to complete these items when 

reporting an injury. The proper codes may be found in OSHA 

Booklet 2014, "Recordkeeping and Reporting Guidelines."

OWCP Agency Code

This is a four-digit (or four digit plus two letter) code used by 

OWCP to identify the employing agency. The proper code may 

be obtained from your personnel or compensation office, or by 

contacting OWCP.