308 lines
14 KiB
Plaintext
308 lines
14 KiB
Plaintext
English French Notes Complete/Exclude
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23. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE
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245 NAME OF PHYSICIAN.............//^S X=PNAME;I X=
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246 STREET ADDRESS................//^S X=PADD
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249 ZIP CODE......................//^S X=PZIP
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250 24. 1ST DATE MEDICAL CARE RECEIVED
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251 25. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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252 26. DATE EMPLOYEE FIRST REPORTED CONDITION TO SUPERVISOR.
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253 27. DATE/TIME EMPLOYEE STOPPED WORK..
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254 28. DATE/TIME EMPLOYEE'S PAY STOPPED.
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255 29. DATE EMPLOYEE WAS LAST EXPOSED TO CONDITIONS ALLEGED TO HAVE CAUSED DISEASE OR ILLNESS...............
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256 30. DATE/TIME RETURNED TO WORK.......
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31. IF EMPLOYEE HAS RETURNED TO WORK AND WORK ASSIGNMENT HAS CHANGED, DESCRIBE NEW DUTIES
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Invalid character entered, (~,`,@,#,$,%,^,*,_,|,\,},{,[,],>, or <),
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. Please edit.
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61 OTHER RETIREMENT..............
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258 33. WAS INJURY CAUSED BY 3RD PARTY;I X=
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259 34. NAME OF THIRD PARTY...........
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260 STREET ADDRESS................
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263 ZIP CODE......................
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Signature of Supervisor
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NAME OF SUPERVISOR:
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269 OFFICE PHONE......
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26 GENERAL SETTING OF INCIDENT........;S X=X;
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27 LOCATION OF INJURY.................;S X=X;D CARE2^OOPSUTL2(IEN);
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28 DESCRIPTION OF INCIDENT............
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29.5 HOW IS INCIDENT RELATED TO MEDICAL EMERGENCY
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29 CHARACTERIZATION OF INJURY.........
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30 BODY PART MOST AFFECTED............
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30.1 ADDITIONAL BODY PART AFFECTED......
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31 SIDE OF BODY AFFECTED..............;S X=X;
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34 PATIENT SOURCE.....................
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36 PURPOSE OF SHARP OBJECT...........
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37 ACTIVITY AT TIME OF INJURY........
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38 OBJECT CAUSING INJURY.............;S X=X;
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83 DEVICE SIZE.......................
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41 BODILY FLUID EXPOSURE SOURCE.......
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42.5 WAS THERE AN EQUIPMENT/DEVICE/PRODUCT FAILURE//^S X=FAIL;I X=
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42 DESCRIBE EQUIPMENT/DEVICE/PRODUCT FAILURE..
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43 SAFETY DESIGN DEVICE USED....;S X=X;
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87 DID THE INJURY OCCUR BEFORE THE SAFETY DEVICE WAS ENGAGED..
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84 SAFETY CHARACTERISTICS.......
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85 EXPLAIN WHY A SAFETY DEVICE WAS NOT USED...
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32 DUTY RETURNED TO...................
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33 LOST TIME..........................;S X=X;
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47 CORRECTIVE ACTION............
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for Continuation of Pay/Compensation (Form CA-1)
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130 17. AGENCY NAME...............//^S X=AGN;I X=
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131 STREET ADDRESS............//^S X=ADD
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134 ZIP CODE..................//^S X=ZIP
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176 18. EMPLOYEE'S DUTY STATION...
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177 STREET ADDRESS............
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180 ZIP CODE..................
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61 OTHER RETIREMENT...........
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20. REGULAR WORK HOURS:
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21. REGULAR WORK SCHEDULE.....:
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4 22. DATE/TIME INJURY OCCURRED.......//^S X=DTINJ
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175 23. DATE OF NOTICE RECEIVED...//^S X=DT110
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142 24. DATE/TIME STOPPED WORK....
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143 25. DATE PAY STOPPED..........
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144 26. DATE 45 DAY PERIOD BEGAN..
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145 27. DATE/TIME RETURNED TO WORK
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146 28. WAS EMPLOYEE INJURED IN PERFORMANCE OF DUTY;I X=
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148 29. WAS INJURY CAUSED BY EMPLOYEE'S WILLFUL MISCONDUCT, INTOXICATION, OR INTENT TO INJURE SELF OR ANOTHER;I X=
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150 30. WAS INJURY CAUSED BY 3RD PARTY;I X=
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31. NAME AND ADDRESS OF THIRD PARTY:
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151 NAME OF THIRD PARTY.......;I X=
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152 STREET ADDRESS............
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155 ZIP CODE..................
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32. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE:
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156 NAME OF PHYSICIAN.........//^S X=PNAME;I X=
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157 STREET ADDRESS............//^S X=PADD
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160 ZIP CODE..................//^S X=PZIP
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161 33. 1ST DATE MEDICAL CARE RECEIVED
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162 34. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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163 35. DOES YOUR KNOWLEDGE OF THE FACTS AGREE WITH STATEMENTS OF THE EMPLOYEE;I X=
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165 36. IF THE EMPLOYING AGENCY CONTROVERTS CONTINUATION OF PAY, STATE THE REASON IN DETAIL~
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37. PAY RATE WHEN EMPLOYEE STOPPED WORK:
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Signature of Supervisor and Filing Instructions
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NAME OF SUPERVISOR:
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173 OFFICE PHONE.......
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174 39. FILING INSTRUCTIONS
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Required Cross Reference (
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) was not set up, call your IRM.
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) was not properly destroyed, call your IRM.
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Select Forms:
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form CA1 (Injury)
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form CA2 (Illness)
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Select Forms
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WCES;1,3
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CA1ES;4,6
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CA2ES;4,6
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CA1ES;1,3
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CA2ES;1,3
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Your ES has been cleared. You will need to resign.
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Invalid character entered (~,`,@,#,$,%,*,_,|,\,},{,[,],>, or <)
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WAS THERE AN EQUIPMENT/DEVICE/PRODUCT FAILURE
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Enter Yes or No to indicate that it was a failure of an device.
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Was the exposed part:
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Select the Area Type:
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GENERAL SETTING OF
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Select the area type to be used.
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NON-PATIENT
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CARE AREA:
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Enter the employee's work schedule at the time of the incident.
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The numbers 1-7 correspond to the days of the week.
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Enter the day numbers as a range or list separated by commas.
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Examples: For Mon-Fri enter 2-6 (or 2,3,4,5,6)
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For Wed-Sat enter 4-7 (or 4,5,6,7)
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For Mon,Wed,Fri enter 2,4,6
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Range exceeds 1-7 limit.
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. A supervisor who knowingly certifies to any false statement,
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misrepresentation, concealment of fact, etc., in respect of
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this claim may also be subject to appropriate felony criminal
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I certify that the information given above and that furnished
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by the employee is true to the best of my knowledge with the
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following exception.
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Sun,Mon,Tue,Wed,Thu,Fri,Sat
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cannot be more than
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years in the past.
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DOB cannot be after
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Enter the person's name, using the format LASTNAME,FIRSTNAME.
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Suffixes such as Sr, Jr, III can only be entered as a FIRSTNAME.
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There must be a LAST NAME and FIRST NAME separated by a comma.
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Spaces in the last name are not allowed and the only
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punctuation allowed is a hyphen (-) or comma (,).
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Witness Data is incomplete for the following Witnesses, enter missing data.
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is missing the
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Date of Witness Signature cannot be prior to DATE/TIME OF OCCURRENCE.
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Address or City contains invalid characters:
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(~,`,@,#,$,%,*,_,|,\,},{,[,],>,or <). Please Edit
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YOU LAST SELECTED:
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. REGULAR WORK SCHEDULE:
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SELECT THE DAYS OF THE WEEK:
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ENTER THE NUMBER OF THE DAY/S OF THE WEEK WORKED
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1-3,6,7 WOULD BE:
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SUNDAY THRU TUESDAY, FRIDAY AND SATURDAY.
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cannot be blank if date entered in
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Validating data on form
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This date cannot be prior to DATE/TIME INJURY OCCURRED entered on 2162.
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Invalid Physician Name format.
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Invalid Witness Name format.
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REASON FOR CONTROVERT COP exceeds 528 character limit set by DOL.
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SUPERVISOR NOT AGREE EXPLAIN exceeds 528 character limit set by DOL.
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RELATIONSHIP OF ILLNESS TO EMP exceeds 528 character limit set by DOL.
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NATURE OF DISEASE/ILLNESS exceededs 264 character limit set by DOL.
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CLAIM NOT FILED exceeds 528 character limit set by DOL.
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EMPLOYEE STATEMENT DELAYED exceeds 528 character limit set by DOL.
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MEDICAL REPORT DELAYED exceeds 528 character limit set by DOL.
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WORK DUTY CHANGED exceeds 528 character limit set by DOL.
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OOPS SIGNATURE SECURITY
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OK to transmit to DOL
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My consent is given for the release of case number
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information for review by local bargaining units for accident and
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illness tracking purposes only. Name, address, social security
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number, date of birth, and telephone number will not be included
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in the information provided to the bargaining units.
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With your consent, the following information will be provided
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to the local bargaining unit for your review.
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Dt/Tme Occurrence:
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Personnel Status:
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Station Number:
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Cost Center/Org:
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Type Incid:
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Secondary Super:
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72Consent Given://^S X=
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If you give consent, you will be prompted to select the
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Union to send the bulletin to. The bulletin will be sent
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immediately after the Union has been selected.
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Select UNION to send bulletin to:
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Cannot sent a bulletin to Union, No Union Representative name was selected
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or one is not on file. Contact your Workers' Compensation Specialist.
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You '^'d out, Do you want to Sign
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OOPS(2260,IEN,
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Are you signing for the Supervisor
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The Supervisor has not signed the
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. To continue
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editing, you will need to sign as Supervisor.
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Sign as Supervisor
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Supervisor has not signed
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This person is not in the PAID Employee File and does not appear
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eligible to submit a claim to DOL. Please check with your
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Human Resources Department for assistance. Sending a paper
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hardcopy may be necessary, if allowable.
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This person does not appear to be eligible for submitting a claim
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to DOL, please review the RETIREMENT, GRADE, STEP, PAY
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PLAN, PAY RATE and PAY RATE PER Fields. You may need to
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contact your Human Resources Department or IRM for assistance.
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Worker's Comp edit of special fields occurred, Supervisor
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signature fields cleared, you will need to sign as Supervisor.
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Worker's Compensation Signing for Supervisor
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Signature of Supervisor and Filing Instructions
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NAME OF SUPERVISOR.:
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173 OFFICE PHONE.......;I X=
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Worker's Comp Edit of Supervisor's Report
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73 OWCP DISTRICT OFFICE......//^S X=WCPDO
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70 OWCP CHARGEBACK CODE......//^S X=OWCP
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62 OWCP NOI CODE.............
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NOI Code must begin with a T for a CA1.
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122 14a. OCCUPATION CODE...........
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123 14b. TYPE CODE.................
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124 14c. SOURCE CODE...............
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130 17. AGENCY NAME...............//^S X=AGN;I X=
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131 STREET ADDRESS............//^S X=ADD
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134 ZIP CODE..................//^S X=ZIP
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176 18. EMPLOYEE'S DUTY STATION...
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177 STREET ADDRESS............
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180 ZIP CODE..................
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61 OTHER RETIREMENT..........
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20. REGULAR WORK HOURS:
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21. REGULAR WORK SCHEDULE.....:
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4 22. DATE/TIME INJURY OCCURRED.......//^S X=DTINJ
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175 23. DATE OF NOTICE RECEIVED...//^S X=DT110
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142 24. DATE/TIME STOPPED WORK....
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143 25. DATE PAY STOPPED..........
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144 26. DATE 45 DAY PERIOD BEGAN..
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145 27. DATE/TIME RETURNED TO WORK
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146 28. WAS EMPLOYEE INJURED IN PERFORMANCE OF DUTY;I X=
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148 29. WAS INJURY CAUSED BY EMPLOYEE'S WILLFUL MISCONDUCT, INTOXICATION, OR INTENT TO INJURE SELF OR ANOTHER;I X=
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150 30. WAS INJURY CAUSED BY 3RD PARTY;I X=
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31. NAME AND ADDRESS OF THIRD PARTY:
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151 NAME OF THIRD PARTY.......;I X=
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152 STREET ADDRESS............
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155 ZIP CODE..................
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32. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE:
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156 NAME OF PHYSICIAN.........//^S X=PNAME;I X=
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157 STREET ADDRESS............//^S X=PADD
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160 ZIP CODE..................//^S X=PZIP
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161 33. 1ST DATE MEDICAL CARE RECEIVED
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162 34. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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163 35. DOES YOUR KNOWLEDGE OF THE FACTS AGREE WITH STATEMENTS OF THE EMPLOYEE;I X=
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165.1 36a. DOES THE AGENCY CONTROVERT THIS CLAIM;S CONT=X
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165.2 36b. DOES THE AGENCY DISPUTE THIS CLAIM...
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165 36. IF THE EMPLOYING AGENCY CONTROVERTS CONTINUATION OF PAY, STATE THE REASON IN DETAIL~
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37. PAY RATE WHEN EMPLOYEE STOPPED WORK:
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174 39. FILING INSTRUCTIONS
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Worker's Comp Edit of the Supervisor's Report
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NOI Code cannot begin with a T for a CA2.
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224 9a. OCCUPATION CODE...............
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226 14b. TYPE CODE.....................
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227 14c. SOURCE CODE...................
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230 19. AGENCY NAME...................//^S X=AGN;I X=
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231 STREET ADDRESS................//^S X=ADD
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234 AGENCY ZIP CODE...............//^S X=ZIP
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237 20. EMPLOYEE'S DUTY STATION.......
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238 STREET ADDRESS................
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241 ZIP CODE......................
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21. REGULAR WORK HOURS:
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22. REGULAR WORK SCHEDULE.........:
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23. NAME AND ADDRESS OF PHYSICIAN FIRST PROVIDING MEDICAL CARE
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245 NAME OF PHYSICIAN.............//^S X=PNAME;I X=
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246 STREET ADDRESS................//^S X=PADD
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249 ZIP CODE......................//^S X=PZIP
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270 PHYSICIAN TITLE...............//^S X=PTITLE
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250 24. 1ST DATE MEDICAL CARE RECEIVED
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251 25. DO MEDICAL REPORTS SHOW EMPLOYEE IS DISABLED FOR WORK
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252 26. DATE EMPLOYEE FIRST REPORTED CONDITION TO SUPERVISOR.
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253 27. DATE/TIME EMPLOYEE STOPPED WORK..
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254 28. DATE/TIME EMPLOYEE'S PAY STOPPED.
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255 29. DATE EMPLOYEE WAS LAST EXPOSED TO CONDITIONS ALLEGED TO HAVE CAUSED DISEASE OR ILLNESS...............
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256 30. DATE/TIME RETURNED TO WORK.......
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31. IF EMPLOYEE HAS RETURNED TO WORK AND WORK ASSIGNMENT HAS CHANGED, DESCRIBE NEW DUTIES
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Invalid character entered, (~,`,@ ,#,$,%,^,*,_,|,\,},{,[,],>, or <),
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Workers Comp signing for Supervisor
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if you continue, your ES will be removed
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The SAFETY DEVICE USED Field (#43) in the ASISTS ACCIDENT REPORTING
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File (#2260) has been changed. Unknown has been removed as a
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valid code for this field. All records with Unknown will be
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changed to 'N'o.
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OOPS*1.0*11
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Data Conversion in Progress...
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Safety Device changed from Unknown to No for this case
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Station # for Case #:
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, could not be Converted,
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Update Manually.
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ASISTS Cases have been Updated with Station Number.
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Hollow Bore Needlestick
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Exposure to Body Fluids/Splash
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Suture Needlestick
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Drill bit/burr
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Blunt Suture Needle
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Table Files have been Updated.
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The PAY RATE PER Field (#167) in the ASISTS ACCIDENT REPORTING
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File (#2260) has been changed from a free text field to a
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set of codes field.
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This routine will convert the current data in the PAY RATE PER
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field for cases that a valid code can be determined.
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The Set of Codes are:
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Any case that the correct code cannot be determined for will
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be included in the install file and the PAY RATE PER data deleted.
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An option is provided with the patch that will allow
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a user to correct the data after installation of the patch.
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If required (cases are present with data that could not be
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converted), install the option as a secondary menu on the
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appropriate users' menu and instruct them to make the data
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OOPS*1.0*8
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Pay Rate Per cannot be converted for Case
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Pay Rate Per Conversion complete.
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Table updates completed.
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Modifying ASISTS DOL CAUSE OF INJURY CODE Table File (#2263.2)
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Modifying ASISTS DOL SOURCE OF INJURY CODES Table File (#2263.1)
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Hand tool (powered: saw
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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