It is recommended that you take a Form CA-17 - Duty Status Report with you to give to your physician.  This form provides your supervisor and OWCP with interim medical reports containing information as to your ability to return to any type of work.  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.

Form CA-17:  Side A

Side A is to be completed by the employee’s supervisor.  On this side of the form, the employee’s supervisor must specify which physical actions the injured worker’s job entails and the duration of those actions.  It specifies how much weight the employee is required to lift and/or carry and if they carry/lift it on an intermittent or continuous basis.  It also specifies how many hours per day and per week the employee works and how many hours per day each of the physical activities stated are performed.  The form also provides sections for the supervisor to briefly describe how the injury occurred, the body parts affected, and to describe any other actions the employee’s job requires which are not specified elsewhere on the form.

Form CA-17:  Side B

Side B is to be completed by the employee’s treating physician. On Side B, the physician must:

• Specify his or her clinical findings.
• State whether the employee’s medical history of the injury corresponds to the information entered in Section A of the form.
• Provide clinical findings.
• Provide a diagnosis due to the injury.
• State whether the employee has been advised by the doctor to return to work, and, if so,
• Can the employee return to his/her regular job duties.

If the physician answers “No” to the employee returning to his/her regular job duties, he/she must then proceed to enter the same information regarding specific job activities, as the supervisor did.  However, the physician must enter the information specifying if the employee is allowed to perform those activities and, if so, for how long and state how much the activities may be performed on a continuous and/or intermittent basis.  The physician also must specify how much weight the employee may lift / carry.

Notice that this form ONLY specifies on-the-job duties and restrictions.  It does not mention the employee’s life outside the job. Notice also that the directions on the form state that the supervisor is to complete Section A and then forward the CA-17 to the employee’s treating physician for the doctor to complete Section B.  If the supervisor follows these directions properly, the supervisor does not see the employee’s diagnosis, other disabling conditions, or the physician’s clinical findings as these items are to be completed by the physician after the supervisor completes his Section A and sends the form to the doctor.

Do not submit your CA-17 Duty Status Report to your federal employing agency.  Send it directly to your OWCP Claims Examiner in London, Kentucky.