Official Legal Form
Duty Status Report
Published by US Dept. of Labor — Forms. Mirrored here in its unmodified, original form for free public access.
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Duty Status Report U.S. Department of Labor
Office of Workers' Compensation Programs
This form is provided for the purpose of obtaining a duty status report for the employee named below. This request OMB No. 1240-0046
does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any previous
Expires: 08/31/2026
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. Information collected will be handled and stored in compliance with the Freedom of Information Act, the OWCP File Number
Privacy Act of 1974 and the OMB Cir. A-130. Persons are not required to respond to this collection of information unless it (If known)
displays a currently valid OMB control number.
SIDE A - Supervisor: Complete this side and refer to physician SIDE B - Physician: Complete this side
1. Employee's Name (Last, first, middle) 8. Does the History of Injury Given to You by the Employee
Correspond to that Shown in Item 5? Yes No (If not, describe)
2. Date of Injury (Month, day, yr.) 3. Social Security Number
4. Occupation 9. Description of Clinical Findings
5. Describe How the Injury Occurred and State Parts of the Body Affected
10.Diagnosis(es) Due to Injury 11. Other Disabling Conditions
12. Employee Advised to Resume Work?
6. The Employee Works
Yes, Date Advised No
Hours Per Day Days Per Week
13. Employee Able to Perform Regular Work Described on Side A?
7. Specify the Usual Work Requirements of the Employee. Check
Yes, If so Full-Time or Part-Time Hrs Per Day
Whether Employee Performs These Tasks or is Exposed Continuously
or intermittently, and Give Number of Hours. No, If not, complete below:
Activity Continuous Intermittent Continuous Intermittent
a. Lifting/Carrying: #Ibs. #Ibs. #Ibs. #Ibs.
State Max Wt. Hrs Per Day Hrs Per Day
b. Sitting Hrs Per Day Hrs Per Day
c. Standing Hrs Per Day Hrs Per Day
d. Walking Hrs Per Day Hrs Per Day
e. Climbing Hrs Per Day Hrs Per Day
f. Kneeling Hrs Per Day Hrs Per Day
g. Bending/Stooping Hrs Per Day Hrs Per Day
h. Twisting Hrs Per Day Hrs Per Day
i. Pulling/Pushing Hrs Per Day Hrs Per Day
j. Simple Grasping Hrs Per Day Hrs Per Day
k. Fine Manipulation
Hrs Per Day Hrs Per Day
(includes keyboarding)
l. Reaching above
Hrs Per Day Hrs Per Day
Shoulder
m. Driving a Vehicle
Hrs Per Day Hrs Per Day
(Specify)
n. Operating Machinery
Hrs Per Day Hrs Per Day
(Specify)
o. Temp. Extremes
range in degrees F range in degrees F
p. High Humidity Hrs Per Day Hrs Per Day
q. Chemicals, Solvents,
Hrs Per Day Hrs Per Day
etc. (Identify)
r. Fumes/Dust (identify) Hrs Per Day Hrs Per Day
s. Noise (Give dBA) dBA dBA
Hrs Per Day Hrs Per Day
t. Other (Describe) 14. Are Interpersonal Relations Affected Because of a Neuropsychiatric Condition?
(e.g. Ability to Give or Take Supervision, Meet Deadlines, etc.)
Yes No (Describe)
15. Date of Examination 16. Date of Next Appointment
17. Specialty 18. Tax Identification Number
If you have a disability and are in need of communication assistance (such as
alternate formats or sign language interpretation), accommodations and/or
modifications, please contact OWCP. See form instructions for Requests for 19. Physician's Signature 20. Date CA-17 (Rev. 04/2020)
Accommodations or Auxiliary Aids and Services
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: Complete Side B, sign and return to the employing agency within 2 days
to prevent interruption of the employee's income. Fill in your name and address.
Medical Facility Name and Address
Send Original Report to:
Employing Agency Address
Send a Copy of this Report to:
Office of Workers’ Compensation Programs
Division of Federal Employees’, Longshore and Harbor Workers’ Compensation
Federal Employees’ Compensation Act
(OWCP/DFELHWC-FECA)
PO Box 8311
London, KY 40742-8311
Certification
By signing block 19 on the front of this form, the physician certifies as follows:
I certify that all the statements in response to the questions asked on this form ca-17 are true,
complete and correct to the best of my knowledge. Further, i understand that any knowingly false or
misleading statement, or misrepresentation or concealment of material fact, may subject me to
criminal prosecution.
I further understand that this request does not constitute authorization for payment of medical
expenses by the department of labor, nor does it invalidate any previous authorization issued in this
case.
Notice
Requests for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP in the form of
communication assistance, accommodation(s) and/or modification(s) to aid you in the claims
process. For example, we will provide you with copies of documents in alternate formats,
communication services such as sign language interpretation, or other kinds of adjustments or
changes to accommodate your disability. Please contact our office or your OWCP claims examiner
to ask about this assistance.
CA-17 PAGE 2 (Rev. 04/2020)
Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5 U.S.C.552a), you are here by notified
that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101,
et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S.
Department of Labor, which receives and maintains personal information on claimants and their
immediate families. (2) Information which the Office has will be used to determine eligibility for
and the amount of benefits payable under the FECA, and may be verified through computer
matches or other appropriate means. (3) Information may be given to the Federal agency which
employed the claimant at the time of injury in order to verify statements made, answer questions
concerning the status of the claim, verify billing, and to consider issues relating to retention,
rehire, or other relevant matters. (4) Information may also be given to other Federal agencies,
other government entities, and to private-sector agencies and/or employers as part of
rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to
physicians and other healthcare providers for use in providing treatment or medical/vocational
rehabilitation, making evaluations for the Office, and for other purposes related to the medical
management of the claim. (6) Information may be given to Federal, state and local agencies for
law enforcement purposes, to obtain information relevant to a decision under the FECA, to
determine whether benefits are being paid properly, including whether prohibited dual payments
are being made, and, where appropriate, to pursue salary/administrative offset and debt
collection actions required or permitted by the FECA and/or the Debt Collection Act. (7)
Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this
form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be
used for identification, to support debt collection efforts carried on by the Federal government,
and for other purposes required or authorized by law. (8) Failure to disclose all requested
information may delay the processing of the claim or the payment of benefits, or may result in an
unfavorable decision or reduced level of benefits.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this
collection of information unless it displays a currently valid OMB control number. Public reporting
burden for this collection of information is estimated to average 5 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. The obligation to
respond to this collection is required to obtain or retain a benefit under 5 U.S.C 8101, et seq. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Office of
Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington,
DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not send the
completed form to this office.
CA-17 PAGE 3 (Rev. 04/2020)
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