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Chapter 1General 214 Authorizing Medical
Purpose and Scope 216 LimitedFull Duty
17 other sections not shown
amount and/or annual leave assigned attached Check appropriate box claimant CLAlM completes items Completing Form continuation of pay control office control office/point control register controversion COP hours copy Date and Hour date of injury Department of Labor Employee Received employee returned employing agency Employment Standards Administration Exhibit FECA Federal Employees Form CA-1 GlVE health benefits Hrs Per Day identified injured employee injury compensation personnel Injury Compensation Program injury/illness installation head job-related LABOR Employment Standards lf Yes limited duty ltem LWOP status middle name Name and Address number of hours occupational disease occupational illness Office of Workers OWCP District Office OWCP file number Pay Rate Pay Stopped payments period of COP period of disability procedures provides recovery recurrence refer Rehabilitation request responsible RICPA scheduled Self-explanatory sick leave sick or annual Signature social security number Standards Administration Office statement supervisor traumatic injury U.S. Department U.S. Postal Service USPS Zip Code