Summary. Instructions HBK EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS

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1 OWCP Form CA-3 Instructions Report of Termination of Disability and/or Payment Summary Purpose The purpose of this form is to notify the OWCP of the following: a. Disability from injury or illness has terminated. b. Continuation of pay (COP) has terminated. c. The employee has returned to duty. Note: CA-3 need not be completed if the above information has been previously submitted on Form CA-1, CA-2, or otherwise. However, some OWCP District Offices still request a CA-3 whenever either a, b, or c above is reported. General Procedures and Preparation Responsibilities a. Upon notification or receipt of information that the employee satisfied either a, b, or c, under Purpose the ICCO will initiate the CA-3. b. If the employee has been on the OWCP periodic roll, the ICCO should immediately telephone the OWCP advising the date the employee returned to work or overcame the disability. This will preclude an overpayment. Filing and Distribution For filing and distributing, do the following: a. Send the original CA-3 to the OWCP. b. File a copy of the CA-3 in the claimant s injury compensation file. Instructions 1. Claimant s complete name: last name, first name, and middle name (enter NMN if no middle name). 2. SSN consists of nine digits. 3. The OWCP file number from original traumatic (CA-1) or occupational (CA-2) claim. Verify that date in Item 7, below, agrees with original claim date. 4. U. S. Postal Service 5. Address of employing establishment at time of original injury or disease. 6. Address of control office authorized to forward to or communicate with the OWCP. 391

2 7. Date and hour of original injury or disease as shown on the CA-1 (Item 10) or CA-2 (Item 29). 8. a. If disability caused by a traumatic injury, refer to Item 25 on the original CA-1. b. If disability resulted due to an occupational condition, refer to Item 27 on the original CA-2. c. If disability resulted after a recurrence, refer to Item 10 on the related CA-2a. 9. Month, day, year, and time employee entered a non-pay LWOP status; see instructions for Item 8 in event disability and LWOP commenced upon filing a claim or recurrence. 10. Date employee returned to duty; or, if total disability has ceased and COP terminated, enter date and explain in Item 17, below, and enter Has Not Returned if appropriate. 11. a. If employee has not returned to work, enter NA. b. If employee returns to his or her normal workweek, see either Item 20 on the CA-1, Item 22 on the CA-2, or Item 28 on the CA-2a. c. If employee returns to a workweek other than his or her normal workweek, so indicate. 12. Enter annual or hourly pay data if rate changed since date disability began; otherwise, enter NA. 13. If, during the period of disability, the employee used either sick or annual leave, enter specific dates; indicate holiday or administrative leave used in Item 13c. 14. a. Check No if employee returns to normal duties. b. Check Yes if upon return to duty the employee s duties have been modified, or if the employee was given limited duty. Describe new or modified duties. 15. If the employee was not in a non-pay LWOP status at least one full pay period, enter NA. If the employee was in a non-pay status at least one full pay period, enter the last day of the pay period from that health benefits or life insurance premiums were deducted. Note: See ELM 525 for procedures if employee s health or life insurance was not deducted and the OWCP did not assume payments. 16. Verify entry with HRIS/OPF if during an open season. 17. Enter any comments. Include reason for stopping COP, if employee refused work, etc. Attach supporting documentation. Also, if employee is on periodic roll, notify OWCP by phone immediately. 392

3 Continuation of Pay: Complete this section only if COP was paid during the period of disability identified as beginning in Item 8, above, and the day prior to the date in Item 10, above, unless information was previously submitted on a CA If COP was paid during the period of disability commencing on or after the date in Item 8, above, include the from and through dates this will not include the day on which the employee returned to work. Or, the through date could be the 45th day of COP, or the day prior to the day COP was terminated for cause. 19. Enter appropriate dollar amount. 20. Self-explanatory. 21. If pay rate has changed, enter new base pay; and night differential, Sunday premium and COLA as applicable. 22. Self-explanatory. 23. Title and commercial telephone number. 24. Self-explanatory. 393

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