308 lines
12 KiB
Plaintext
308 lines
12 KiB
Plaintext
English French Notes Complete/Exclude
|
|
INITIAL DOSE..................:
|
|
SECOND DOSE...................:
|
|
ADJUVANT CHEMO W BEAM RADIATION.:
|
|
THYROID HORMONE THERAPY.........:
|
|
Date of 1st course of tx....:
|
|
Date of 1st Surgical Proc...:
|
|
Surgery of primary site F...:
|
|
Surgery of primary site @fac F:
|
|
Radiation therapy to CNS....:
|
|
Hormone therapy.............:
|
|
Hormone therapy @fac........:
|
|
Other treatment.............:
|
|
Other treatment @fac........:
|
|
SURGICAL DX/STAGING PROC DATE: 99/99/9999
|
|
Unknown;
|
|
SURGICAL PROC/OTHER SITE DATE..:
|
|
DATE RADIATION STARTED:......:
|
|
LOCATION OF RADIATION........:
|
|
RADIATION TREATMENT VOLUME...:
|
|
REGIONAL TREATMENT MODALITY..:
|
|
REGIONAL DOSE:cGy............:
|
|
BOOST TREATMENT MODALITY.....:
|
|
BOOST DOSE:cGy...............:
|
|
NUMBER OF TREATMENTS.........:
|
|
DATE RADIATION ENDED.........:
|
|
CHEMOTHERAPY DATE:.............:
|
|
HORMONE THERAPY DATE:..........:
|
|
IMMUNOTHERAPY DATE:............:
|
|
HEMA TRANS/ENDOCRINE PROC DATE.:
|
|
SURG PROC/OTHER SIT @FAC...(R):
|
|
SURGICAL PROC/OTHER SITE @FAC..:
|
|
RADIATION @FAC...............:
|
|
RADIATION @FAC DATE..........:
|
|
CHEMOTHERAPY @FAC..............:
|
|
CHEMOTHERAPY @FAC DATE.........:
|
|
HORMONE THERAPY @FAC...........:
|
|
HORMONE THERAPY @FAC DATE......:
|
|
IMMUNOTHERAPY @FAC.............:
|
|
IMMUNOTHERAPY @FAC DATE........:
|
|
Select case to be amended:
|
|
Case number
|
|
has been assigned to this amended incident.
|
|
Use option
|
|
Edit Report of Incident
|
|
to complete this case.
|
|
NAME OF EMPLOYEE...............:
|
|
SSN............................:
|
|
DOB............................:
|
|
SEX............................:
|
|
HOME TELEPHONE.................:
|
|
GRADE/STEP.....................:
|
|
PAY PLAN.......................:
|
|
EMPLOYEE'S ADDRESS.............:
|
|
CITY...........................:
|
|
STATE..........................:
|
|
ZIP............................:
|
|
DEPENDENTS.....................:
|
|
PLACE WHERE INJURY OCCURRED....:
|
|
STREET WHERE INJURY OCCURRED...:
|
|
CITY WHERE INJURY OCCURRED.....:
|
|
STATE WHERE INJURY OCCURRED....:
|
|
ZIP CODE WHERE INJURY OCCURRED.:
|
|
DATE/TIME OF OCCURRENCE........:
|
|
DATE OF THIS NOTICE............:
|
|
EMPLOYEE'S OCCUPATION..........:
|
|
CAUSE OF INJURY CODE...........:
|
|
CAUSE OF INJURY................:
|
|
NATURE OF INJURY...............:
|
|
REQUEST PAY OR LEAVE...........:
|
|
EMPLOYEE DATE OF SIGNATURE.....:
|
|
WITNESS INFORMATION:
|
|
NAME OF WITNESS................:
|
|
WITNESS ADDRESS................:
|
|
WITNESS CITY...................:
|
|
WITNESS STATE..................:
|
|
WITNESS ZIP CODE...............:
|
|
DATE OF WITNESS SIGNATURE......:
|
|
STATEMENT OF WITNESS...........:
|
|
OCCUPATION CODE................:
|
|
NOI CODE.......................:
|
|
TYPE CODE......................:
|
|
SOURCE CODE....................:
|
|
OWCP CHARGEBACK CODE...........:
|
|
AGENCY NAME....................:
|
|
AGENCY ADDRESS.................:
|
|
AGENCY CITY....................:
|
|
AGENCY STATE...................:
|
|
AGENCY ZIP CODE................:
|
|
EMPLOYEE'S DUTY STATION........:
|
|
DUTY STATION ADDRESS...........:
|
|
DUTY STATION CITY..............:
|
|
DUTY STATION STATE.............:
|
|
DUTY STATION ZIP CODE..........:
|
|
EMPLOYEE RETIREMENT COVERAGE...:
|
|
EMP RETIREMENT COVERAGE DESC...:
|
|
REGULAR HRS FROM TIME..........:
|
|
REGULAR HRS TO TIME............:
|
|
REGULAR WORK SCHEDULE..........:
|
|
DATE OF INJURY.................:
|
|
DATE NOTICE RECEIVED...........:
|
|
DATE/TIME STOPPED WORK.........:
|
|
DATE PAY STOPPED...............:
|
|
DATE 45 DAY PERIOD BEGAN.......:
|
|
DATE/TIME RETURNED TO WORK.....:
|
|
INJURED PERFORMING DUTY........:
|
|
NOT INJURED PERFORMING JOB.....:
|
|
INJURY CAUSED BY EMPLOYEE......:
|
|
CAUSED BY EMPLOYEE EXPLAIN.....:
|
|
INJURY CAUSED BY 3RD PARTY.....:
|
|
3RD PARTY NAME.................:
|
|
3RD PARTY ADDRESS..............:
|
|
3RD PARTY CITY.................:
|
|
3RD PARTY STATE................:
|
|
3RD PARTY ZIP CODE.............:
|
|
PROVIDING PHYSICAN NAME........:
|
|
PROVIDING PHYSICIAN ADDRESS....:
|
|
PROVIDING PHYSICIAN CITY.......:
|
|
PROVIDING PHYSICIAN STATE......:
|
|
PROVIDING PHYSICIAN ZIP CODE...:
|
|
PROVIDING PHYSICIAN TITLE......:
|
|
FIRST DATE OF MEDICAL CARE.....:
|
|
DISABLED FOR WORK..............:
|
|
SUPERVISOR AGREE/DISAGREE......:
|
|
SUPERVISOR NOT AGREE EXPLAIN...:
|
|
REASON FOR CONTROVERTS COP.....:
|
|
PAY RATE WHEN WORK STOPPED.....:
|
|
SUPERVISOR EXCEPTION...........:
|
|
NAME OF SUPERVISOR.............:
|
|
SUPERVISOR'S DATE OF SIGNATURE.:
|
|
SUPERVISOR'S TITLE.............:
|
|
SUPERVISOR'S OFFICE PHONE......:
|
|
FILING INSTRUCTIONS............:
|
|
Case #
|
|
ILLNESS OCCURRED (LOCATION)....:
|
|
ILLNESS OCCURRED ADDRESS.......:
|
|
ILLNESS OCCURRED CITY..........:
|
|
ILLNESS OCCURRED STATE.........:
|
|
ILLNESS OCCURRED ZIP CODE......:
|
|
DATE FIRST AWARE OF ILLNESS....:
|
|
DATE FIRST REALIZED CAUSE.......:
|
|
RELATIONSHIP OF ILLNESS TO EMP.:
|
|
NATURE OF DISEASE/ILLNESS......:
|
|
REASON CLAIM NOT FILED.........:
|
|
EMPLOYEE STATEMENT DELAY.......:
|
|
REASON MEDICAL REPORT DELAYED..:
|
|
DATE OF EMPLOYEE SIGNATURE.....:
|
|
1ST PROVIDING PHYSICAN NAME....:
|
|
1ST PROVIDING PHYS. ADDRESS....:
|
|
1ST PROVIDING PHYS. CITY.......:
|
|
1ST PROVIDING PHYS. STATE......:
|
|
1ST PROVIDING PHYS. ZIP CODE...:
|
|
1ST PROVIDING PHYS. TITLE......:
|
|
DATE 1ST REPORTED TO SUPERVISOR:
|
|
DATE/TIME WORK STOPPED.........:
|
|
DATE OF LAST EXPOSURE..........:
|
|
WORK DUTY CHANGED..............:
|
|
EMP RETIREMENT COVERAGE DESC.:
|
|
Case number
|
|
will be assigned to this incident.
|
|
2 PERSONNEL STATUS.........
|
|
PERSON INVOLVED..........:
|
|
No SSN on file in the New Person file. Must enter to create case.
|
|
This person (SSN) is a 'PAID' Employee, Please Re-enter
|
|
1 PERSON INVOLVED..........
|
|
Social Security Number is Required
|
|
Date of Birth is required
|
|
Sex is Required
|
|
8 HOME STREET ADDRESS......
|
|
Invalid character entered, (~,`,@,#,$,%,*,_,|,\,},{,[,],>, or <),
|
|
please edit.
|
|
11 ZIP CODE.................
|
|
12 HOME PHONE NUMBER........
|
|
Phone number must include area code and 7 digits only. Example 703-123-8789
|
|
13 STATION NUMBER...........//^S X=STN
|
|
4 DATE/TIME INJURY OCCURRED
|
|
4 DATE 1ST AWARE OF ILLNESS
|
|
3 TYPE OF INCIDENT.........
|
|
VOLUNTARY SVC SUPERVISOR.
|
|
CONTRACT ADMINISTRATOR...
|
|
SAFETY OFFICER...........
|
|
53.1 SECONDARY SUPERVISOR.....
|
|
This Case will be DELETED!
|
|
Case action
|
|
has been saved.
|
|
The following case(s) are Open with SSN:
|
|
CASE NUMBER:
|
|
PERSON INVOLVED:
|
|
PERSONNEL STATUS:
|
|
PAY PLAN:
|
|
TYPE OF INCIDENT:
|
|
DATE/TIME OF OCCURRENCE:
|
|
INJURY/ILLNESS:
|
|
SUPERVISOR:
|
|
PERSON ENTERING STUB RECORD:
|
|
Is the Current entry a DUPLICATE Case:
|
|
VOLUNTARY SVC SUP......:
|
|
CONTRACT ADMINISTRATOR.:
|
|
SAFETY OFFICER.........:
|
|
CASE NUMBER............:
|
|
PERSONNEL STATUS.......:
|
|
TYPE OF INCIDENT.......:
|
|
CASE STATUS............:
|
|
PERSON INVOLVED........:
|
|
DATE OF BIRTH..........:
|
|
HOME ADDRESS...........:
|
|
HOME PHONE NUMBER......:
|
|
STATION NUMBER.........:
|
|
COST CENTER/ORG........:
|
|
SECONDARY SUPERVISOR...:
|
|
DATE/TIME OF OCCURRENCE:
|
|
Print Employee Bill of Rights
|
|
EMPLOYEES' BILL OF RIGHTS FOR ACCIDENT AND OCCUPATIONAL ILLNESSES
|
|
The Federal Employees' Compensation Act (FECA) describes an employee's
|
|
rights and entitlements to benefits following a work-related
|
|
injury or illness.
|
|
You have the right to file a CA-1 (injury) or CA-2 (illness), to apply
|
|
for compensation.
|
|
Entitlements include the option to receive medical treatment by either
|
|
the VA Employee Health Unit or by your primary care physician.
|
|
You have the right to request union representation.
|
|
For additional information and explanation of your rights and
|
|
responsibilities, contact your Workers' Compensation
|
|
Specialist/Coordinator/Manager.
|
|
You have the right to select the physician or facility to provide
|
|
treatment for the sustained injury or illness. The VA facility is
|
|
available for examination and treatment, but cannot mandate use of
|
|
the facility to the exclusion of your choice of medical care.
|
|
apply for compensation.
|
|
You have the right to union representation at any time.
|
|
OOPS DOL XMIT DATA
|
|
You do not have the required Security Key.
|
|
Press Enter to continue
|
|
Domain not found in the DOMAIN File,
|
|
No Transmission. Press Enter to continue
|
|
Re-transmit cases for what date
|
|
Enter the date of original transmission for cases
|
|
that need to be resent
|
|
Enter 'Y' if you want the CA1/CA2 data placed in mail
|
|
message as part of a tasked job.
|
|
TRANSMIT DOL CA1/CA2 DATA
|
|
Transmission NOT queued, OK to continue
|
|
The Queue Q-AST.MED.VA.GOV has not been created. Please contact your IRM
|
|
Dept. to have Patch XM*999*136 installed; once installed complete manual
|
|
transmission of DOL Data.
|
|
OOPS WC MESSAGE
|
|
The Mail Group OOPS WC MESSAGE is missing.
|
|
Add the Group so that ASISTS data can be transmitted
|
|
to the AAC. Then contact Worker Compensation office
|
|
to complete manual Transmission of DOL Data.
|
|
There are no members of the OOPS WC MESSAGE
|
|
Mail Group.
|
|
Enter at least one member to the group. This person
|
|
will receive messages concerning the transmission of
|
|
ASISTS DOL data to and from the AAC. After adding member
|
|
contact Worker Compensation office to complete manual transmission of DOL data.
|
|
No cases to transmit for requested date
|
|
ASISTS Report on Daily Transmission to the AAC
|
|
ASISTS no claims to process
|
|
There were no claims ready for transmission
|
|
to the Austin Automation Center when the.
|
|
scheduled task last ran.
|
|
Mail Message was not created. Contact Worker Compensation office
|
|
to complete the transmission of ASISTS DOL data.
|
|
ASISTS DOL DATA
|
|
XXX@Q-AST.MED.VA.GOV
|
|
Case:
|
|
has missing required data or word processing fields that are
|
|
larger than DOL requirements. Please edit the case(s); and once completed,
|
|
the cases will be transmitted with the next scheduled transmission.
|
|
ASISTS Record(s) not transmitted for Station
|
|
OOPS WCP
|
|
The following claims have been transmitted to the AAC:
|
|
ASISTS Record(s) transmitted to AAC for Station
|
|
ASISTS Package
|
|
ASISTS DOL Error Notification Message
|
|
An Error Occurred during Processing, check
|
|
Mailman Message for details.
|
|
PRINT CA FORM
|
|
No SSN on file for this Employee
|
|
An Accident Report has not been created for this Employee
|
|
Select Case:
|
|
Claim cannot be signed until the Bill of Rights Statement is understood.
|
|
Checking for Safety and Emp Health Ok to sign for Employee.
|
|
Please enter a Signature Code.
|
|
71I have read and understood the Employee Bill of Rights:
|
|
Notice of Occupational Disease and Claim for Compensation (Form CA-2)
|
|
Employee Data
|
|
1. NAME OF EMPLOYEE......:
|
|
2. SOCIAL SECURITY NUMBER:
|
|
3. DATE OF BIRTH.........:
|
|
12 5. HOME TELEPHONE........
|
|
7. EMPLOYEE'S HOME MAILING ADDRESS:
|
|
8 STREET ADDRESS........
|
|
11 ZIP CODE..............
|
|
Claim Information
|
|
10. LOCATION WHERE YOU WORKED WHEN DISEASE OR ILLNESS OCCURRED:
|
|
210 STREET ADDRESS........
|
|
213 ZIP CODE..............
|
|
214 11. DATE YOU FIRST BECAME AWARE OF DISEASE OR ILLNESS;I X=
|
|
215 12. DATE YOU FIRST REALIZED THE DISEASE OR ILLNESS WAS CAUSED BY YOUR EMPLOYMENT;I X=
|
|
216 13. EXPLAIN THE RELATIONSHIP TO YOUR EMPLOYMENT, AND WHY YOU CAME TO THIS REALIZATION~
|
|
#################### #################### ####################
|
|
#################### #################### ####################
|
|
#################### #################### ####################
|
|
#################### #################### ####################
|
|
#################### #################### ####################
|