Form ca-17 Duty Status Report

U.S. Department of Labor

Duty Status Report
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Employment Standards Administration
Office of Workers' Compensation Programs

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This form is provided for the purpose of obtaining a duty status report for the employee named below. This request
OMB No. 1215-0103
Expires: 10-31-08
does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any
previous authorization issued in this case. This request for information is authorized by law (5 USC 8101 et seq.) and is
OWCP File Number
required to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom
(If known)
of Information Act, the Privacy Act of 1974 and the OMB Cir. A-108. Persons are not required to respond to this
collection of information unless it 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)
3. Social Security No.
2. Date of Injury (Month, day, yr.)
4. Occupation
9. Description of Clinical Findings
5. Describe How the Injury Occurred and State Parts of the Body Affected
10. Diagnosis Due to Injury
12. Employee Advised to Resume Work?

6. The Employee Works
Days Per Week
Hours Per Day
7. Specify the Usual Work Requirements of the Employee. Check
Whether Employee Performs These Tasks or is Exposed
Continuously or intermittently, and Give Number of Hours.
Activity
a. Lifting/Carrying:
State Max Wt.

11. Other Disabling Conditions

Continuous Intermittent
#Ibs.

#Ibs.

Yes, Date Advised
No
/
/
13. Employee Able to Perform Regular Work Described on Side A?
Yes, If so
Full-Time or
Hrs Per Day
Part-Time
No, If not, complete below:
Continuous

Intermittent

#lbs.

#Ibs.

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
(includes keyboarding)

Hrs Per Day

Hrs Per Day

l. Reaching above
Shoulder

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

o. Temp. Extremes

Hrs Per Day
range in
degrees F

Hrs Per Day
range in
degrees F

p. High Humidity

Hrs Per Day

Hrs Per Day

q. Chemicals, Solvents,
etc. (Identify)

Hrs Per Day

Hrs Per Day

r. Fumes/Dust (identify)

Hrs Per Day

Hrs Per Day

s. Noise (Give dBA)

dBA
Hrs Per Day

dBA
Hrs Per Day
14. Are Interpersonal Relations Affected Because of a Neuropsychiatric
Condition? (e.g. Ability to Give or Take Supervision, Meet Deadlines,
etc.)
Yes
No (Describe)

m. Driving a Vehicle
(Specify)
n. Operating Machinery
(Specify)

t. Other (Describe)

15. Date of Examination

16. Date of Next Appointment

17. Specialty

18. Tax Identification Number

19. Physician's Signature

20. Date
Form CA-17
Rev. Jan. 1997

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 the appropriate OWCP
District Office in the spaces 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

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 FELONY 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.
Public Burden Statement

We estimate that it will take an average of 5 minutes to complete this collection of information, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, send them to the OWCP, U.S. Department of Labor, Room S-3229, 200
Constitution Avenue, N.W., Washington, D.C. 20210.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402
G. P. 0. - 2000 - 188-099