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.

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.

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.

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. Side A is to be completed by the employee’s supervisor.

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

State Route 17 (SR 17, locally known as Highway 17) is a state highway in the U.S. state of California that runs from State Route 1 in Santa Cruz to I-280 and I-880 in San Jose.

California's 17th congressional district is a congressional district in the U.S. state of California that is currently represented by Ro Khanna. It is located in the South Bay and East Bay regions of the San Francisco Bay Area. The district includes parts of Alameda County and Santa Clara County.