OWCP File Number 

(If known)

Duty Status Report U.S. Department of Labor 

Office of Workers' Compensation Programs

This form is provided for the purpose of obtaining a duty status report for the employee named below. This request 

does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any previous 

authorization issued in this case. This request for information is authorized by law (5 USC 8101 et seq.) and is required to obtain 

or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the 

Privacy Act of 1974 and the OMB Cir. A-130. Persons are not required to respond to this collection of information unless it 

displays a currently valid OMB control number.

OMB No. 1240-0046 

Expires: 08/31/2026

SIDE A - Supervisor: Complete this side and refer to physician

1. Employee's Name (Last, first, middle)

2. Date of Injury (Month, day, yr.) 3. Social Security Number

4. Occupation

5. Describe How the Injury Occurred and State Parts of the Body Affected

6. The Employee Works

Hours Per Day Days Per Week

7. Specify the Usual Work Requirements of the Employee. Check 

Whether Employee Performs These Tasks or is Exposed Continuously 

or intermittently, and Give Number of Hours.

Activity Continuous Intermittent

a. Lifting/Carrying: 

State Max Wt.

#Ibs. #Ibs.

Hrs Per Day

b. Sitting Hrs Per Day

c. Standing Hrs Per Day

d. Walking Hrs Per Day

e. Climbing Hrs Per Day

f. Kneeling Hrs Per Day

g. Bending/Stooping Hrs Per Day

h. Twisting Hrs Per Day

i. Pulling/Pushing Hrs Per Day

j. Simple Grasping Hrs Per Day

k. Fine Manipulation 

(includes keyboarding) Hrs Per Day

l. Reaching above 

Shoulder Hrs Per Day

m. Driving a Vehicle 

(Specify) Hrs Per Day

n. Operating Machinery 

(Specify) Hrs Per Day

o. Temp. Extremes

range in degrees F

p. High Humidity Hrs Per Day

q. Chemicals, Solvents, 

etc. (Identify) Hrs Per Day

r. Fumes/Dust (identify) Hrs Per Day

s. Noise (Give dBA) dBA 

Hrs Per Day

t. Other (Describe)

SIDE B - Physician: Complete this side

Continuous Intermittent

#Ibs. #Ibs.

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

range in degrees F

Hrs Per Day

Hrs Per Day

Hrs Per Day

dBA 

Hrs Per Day

8. Does the History of Injury Given to You by the Employee 

Correspond to that Shown in Item 5? Yes No (If not, describe)

9. Description of Clinical Findings

10.Diagnosis(es) Due to Injury 11. Other Disabling Conditions

12. Employee Advised to Resume Work?

13. Employee Able to Perform Regular Work Described on Side A?

Yes, If so

No, If not, complete below:

Full-Time or Part-Time Hrs Per Day

14. Are Interpersonal Relations Affected Because of a Neuropsychiatric Condition? 

(e.g. Ability to Give or Take Supervision, Meet Deadlines, etc.)

Yes No (Describe)

15. Date of Examination 16. Date of Next Appointment

17. Specialty 18. Tax Identification Number

19. Physician's Signature 20. Date

Yes, Date Advised No

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. See form instructions for Requests for 

Accommodations or Auxiliary Aids and Services CA-17 (Rev. 04/2020)
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: Complete Side B, sign and return to the employing agency within 2 days 

to prevent interruption of the employee's income. Fill in your name and address.

Send Original Report to:

Send a Copy of this Report to: 

Office of Workers’ Compensation Programs 

Division of Federal Employees’, Longshore and Harbor Workers’ Compensation 

Federal Employees’ Compensation Act 

(OWCP/DFELHWC-FECA) 

PO Box 8311 

London, KY 40742-8311 

Certification 

By signing block 19 on the front of this form, the physician certifies as follows: 

I certify that all the statements in response to the questions asked on this form ca-17 are true, 

complete and correct to the best of my knowledge. Further, i understand that any knowingly false or 

misleading statement, or misrepresentation or concealment of material fact, may subject me to 

criminal prosecution. 

I further understand that this request does not constitute authorization for payment of medical 

expenses by the department of labor, nor does it invalidate any previous authorization issued in this 

case. 

Notice 

Requests for Accommodations or Auxiliary Aids and Services 

If you have a disability, federal law gives you the right to receive help from the OWCP in the form of 

communication assistance, accommodation(s) and/or modification(s) to aid you in the claims 

process. For example, we will provide you with copies of documents in alternate formats, 

communication services such as sign language interpretation, or other kinds of adjustments or 

changes to accommodate your disability. Please contact our office or your OWCP claims examiner 

to ask about this assistance. 

CA-17 PAGE 2 (Rev. 04/2020)

Medical Facility Name and Address

Employing Agency Address
CA-17 PAGE 3 (Rev. 04/2020)

Privacy Act Statement 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C.552a), you are here by 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 healthcare 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 disclose 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. 

Public Burden Statement 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this 

collection of information unless it displays a currently valid OMB control number. Public reporting 

burden for this collection of information is estimated to average 5 minutes per response, including 

time for reviewing instructions, searching existing data sources, gathering and maintaining the 

data needed, and completing and reviewing the collection of information. The obligation to 

respond to this collection is required to obtain or retain a benefit under 5 U.S.C 8101, et seq. Send 

comments regarding the burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, to the U.S. Department of Labor, Office of 

Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, 

DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not send the 

completed form to this office.