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:

All of the Federal Employees Program's online forms (with the exception of Forms CA-16 and CA-27) are available to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form.

Title: ca-17.pdf Author: DOLMAIN Created Date: 6/26/2019 9:31:59 AM

instructions for completing duty status report (ca-17) Complete Side A and refer the form to the physician to complete Side B. Fill in the address of the Employing Agency and the appropriate OWCP

Form CA-17 For common positions in EA, have a pre-prepared CA-17 with the left side completed for the injured worker to provide to their physician. On Form CA-17, the EA should indicate light duty work is available.

INSTRUCTIONS FOR COMPLETING DUTY STATUS REPORT (CA-17) Complete Side A and refer the form to the physician to complete Side B. Fill in the address of the Employing Agency and the appropriate OWCP District Office in the spaces below. Enter the OWCP file number in the top right corner. SUPERVISOR:

This form provides your supervisor and OWCP with interim medical reports containing information as to your ability to return to any type of work. Form CA-17 is designed to be filled out by the injured worker’s supervisor and his/her treating physician to complete. It is split into two sections: A and B. Form CA-17: Side A

The CA-17 is a legal document that determines both an injured worker’s medical restrictions and entitlement to wage-loss compensation benefits. When completed, the CA-17 contains sensitive medical information and is protected under the Privacy Act. There are two sides to the CA-17: Side A is completed

In order to start receiving compensation as an injured federal worker, you are required to fill in certain key forms, with one of these being form CA-17.