ca-17

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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' Compensation
(OWCP - DFEC)
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)