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:

Submit forms online through the Employees' Compensation Operations and Management Portal (ECOMP). On the ECOMP site you can register for an account, initiate a claim, upload documents, submit forms, and access your case. OWCP's Federal Employees Program has made a variety of forms available online. These forms are only available in PDF format.

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:

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.

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.

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

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.

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Form CA-17 - Duty Status Report: This form is provided for purpose of obtaining a medical duty status report for IW. It may be issued initially with Form CA-16. Supervisor/Employing Agency completes agency portion by describing physical requirements of IW's job and noting availability of light or limited duty.