Files > ASISTS ACCIDENT REPORTING

name
ASISTS ACCIDENT REPORTING
number
2260
location
^OOPS(2260,
description
This file contains all information associated with an accident that results in injury and/or illness.
Fields
#NameLocationTypeDetailsIndexDescription
.01case number(+)0;1FREE TEXTBThe case number is automatically assigned when a stub record is created. It is composed of the Fiscal Year concatenated with a 5 digit sequential number. Amended cases will have a alphabetic suffix appended to the original case number.
1person involved(+)0;2FREE TEXTCThis is the name of the employee, volunteer, contractor or other person that was involved in the incident, sustaining an injury or illness. Use the same convention for entering a name as used when entering an employee: LAST,FIRST. John Doe would be entered as DOE,JOHN.
2personnel status(+)0;3SET OF CODES1:Employee
2:Volunteer
3:Contractor
4:Visitor
5:Other
6:Non-PAID Employee
7:Medical Student
8:Nursing Student
9:Other Student
10:Resident Physician
ACThe personnel status of the individual involved in the incident is either employee, volunteer, contractor, visitor or other. Non-PAID Employee includes students and residents.
3type of incident(+)0;4POINTER2261.2This is the critical tracking issue that best characterizes the type of injury sustained.
4date/time of occurrence(+)0;5DATE-TIMEADIf this is an injury, this is the date and time the incident happened. If this is an illness, this is the date the employee first became aware of the disease or illness.
5ssn2162A;1FREE TEXTSSNThis is the Social Security Number of the person involved in this incident.
6date of birth2162A;2DATE-TIMEThis is the date of birth of the person involved in this incident.
7sex2162A;3SET OF CODES1:Male
2:Female
This is the sex of the person involved in this incident.
8home street address2162A;4FREE TEXTThis is the first line of the home street address of the person involved in this incident.
9city2162A;5FREE TEXTThis is the city where this person resides.
10state2162A;6POINTER5This is the State in which this person resides.
11zip code2162A;7FREE TEXTThis is the Zip code for this person's home address.
12home phone number2162A;8FREE TEXTThis is the home phone number of the person involved in this incident. Enter the Area Code and number separated by hyphens or spaces. E.g., 123-122-3456 or 123 122 3456
13station number(+)2162A;9POINTER4DThis is the station number where the incident took place.
14cost center/organization2162A;10FREE TEXTThis is the employee's cost center/organization code.
15occupation2162A;11FREE TEXTThis is the employee's occupation series code.
16grade2162A;12FREE TEXTThis is the employee's grade as of the date of injury.
17step2162A;13FREE TEXTThis is the employee's step as of the date of injury.
18education2162A;14FREE TEXTThis is the employee's education level.
19hepatitis b2162A;15BOOLEANY:Yes
N:No
In cases of bodily fluid exposure (including needlesticks and sharps), this shows whether or not a test for Hepatitis B was done as a result of the exposure.
20hepatitis c2162A;16BOOLEANY:Yes
N:No
In cases of bodily fluid exposure (including needlesticks and sharps), this shows whether or not a test for Hepatitis C was done as a result of the exposure.
21hiv2162A;17BOOLEANY:Yes
N:No
In cases of bodily fluid exposure (including needlesticks and sharps), this shows whether or not a test for HIV was done as a result of the exposure.
22other2162A;18BOOLEANY:Yes
N:No
In cases of bodily fluid exposure (including needlesticks and sharps), this shows whether or not a test other than Hepatitis B, Hepatitis C, or HIV was done as a result of the exposure.
23date ordered2162A;19DATE-TIMEIn cases of bodily fluid exposure (including needlesticks and sharps), this shows the date ordered for lab tests.
24date drawn2162A;20DATE-TIMEFor bodily fluid exposures, this is the date the tests were done.
25follow-up date2162A;21DATE-TIMEThis is the date follow-up should take place.
26general setting of incident(+)2162B;1SET OF CODESP:Patient care setting
N:Non-patient care setting
U:Unknown
This shows whether the incident took place in a patient care or non-patient care setting.
27location of injury(+)2162B;2POINTER2261.4This is the general location, either a patient care or non-patient care type setting, where the incident took place.
28description of incident2162C;0WORD-PROCESSINGThis information fully narrates the accident or incident. It explains what led up to the accident, how the accident happened, equipment failures, material defects, etc.
29characterization of injury2162B;3POINTER2261This is the general description of the injury.
29.5medical emergency2162B;9SET OF CODES1:Normal Operations (No Emergency)
2:Medical Emergency
3:Clean-up Following Medical Emergency
Enter the response that best describes how the incident is related to a medical emergency.
30body part most affected2162B;4POINTER2261.1 Enter the body part most affected by the injury.
30.1additional body part affected2162B;8POINTER2261.1 Enter an additional body part that was affected by the injury.
31side of body affected2162B;5SET OF CODESL:Left
R:Right
B:Both
N:NA
This is the side of the body most affected by the injury.
32duty returned to2162B;6SET OF CODESF:Full duty
L:Light duty
The employee returned to either light or full duty.
33lost time2162B;7BOOLEANY:Yes
N:No
The employee did or did not lose time due to the injury.
34patient source2162D;1SET OF CODESI:Identifiable
U:Unidentifiable
N:NA
This defines whether or not the source patient of the body fluid exposure (including needlestick and sharps) is identifiable.
35contamination2162D;2SET OF CODESY:Yes
N:No
U:Unknown
This states whether or not the needle or sharp was contaminated.
36purpose of sharp object2162D;3POINTER2261.5The sharp item was originally used for this purpose.
37activity at time of injury2162D;4POINTER2261.6This is the activity when the injury occurred.
38object causing injury2162D;5POINTER2261.7This is the device or item that caused the injury.
39area exposed to bodily fluid2162E;0MULTIPLE2260.039This is a description of the exposed body parts.
40personal protective equipment2162F;0MULTIPLE2260.01This is a description of the protective items worn at the time of the exposure.
41bodily fluid exposure source2162D;6POINTER2261.8This explains how the exposure happened.
42equipment/device failure2162D;7FREE TEXTIf there was an equipment, device or product failure, this is the type of equipment and manufacturer name.
42.5equip/device failure occurred2162D;9BOOLEANN:No
Y:Yes
Indicates whether there was an equipment or device product failure involved with the incident. If yes, user will be prompted to enter comments.
43safety design device used2162D;8BOOLEANY:Yes
N:No
This states whether or not a safety device was used.
44supervisor2162ES;1POINTER200This is the supervisor completing the information on the Report of Accident (2162).
45supervisor electronic sig2162ES;2FREE TEXTThis is the supervisor's electronic signature.
46supervisor signature date2162ES;3DATE-TIMEThis is the date the supervisor signed the 2162.
47corrective action2162G;0WORD-PROCESSINGThis is a statement of any corrective action that was taken to prevent further incidents of this kind.
48safety officer name2162ES;4POINTER200This is the name of the safety officer.
49safety off. elect. signature2162ES;5FREE TEXTThis is the safety officer's electronic signature.
50safety off. date signed2162ES;6DATE-TIMEThis is the date of the safety officer's signature.
51case status0;6SET OF CODES0:Open
1:Closed
2:Deleted
3:Replaced by amendment
This is the status of the case.
52injury/illness(+)0;7SET OF CODES1:Injury
2:Illness/disease
If the employee is relating the condition to a single incident, then select Injury (CA-1). If the employee is relating the condition to more than one incident or more than a single shift, then select Illness (CA-2).
53supervisor(+)0;8POINTER200 Enter the name of the supervisor of the person involved.
53.1secondary supervisor0;9POINTER200 Enter the name of the secondary supervisor of the person involved.
54needs xmit to ndb0;18DATE-TIMEThis is the date that the case was determined to be valid for transmission to NDB.
55safety off. comments2162H;0WORD-PROCESSINGThese are comments from the safety officer about this case.
56person entering stub record(+)0;10POINTER200This field is automatically populated when the 2162 Incicent report is created and saved. Data entry for this field is not possible through the ASISTS package. The internal value for this field is a pointer to the NEW PERSON File (#200). The external value (Name) is displayed on the PRINT REPORT OF ACCIDENT Report.
57date transmitted to ndb0;11DATE-TIME The value in this field will be the last time the closed case 2162 data was transmitted to the NDB. If the case is closed, transmitted, then re-opened, this field is 'blanked' so that retransmission will be triggered.
58reason for deletion0;12FREE TEXTEnter the reason the case is being deleted.
59transmitted to ndb0;19BOOLEANY:YES
N:NO
60emp retirement coverage(+)CA;4SET OF CODES1:CSRS
2:FERS
3:OTHER
This is the type of retirement coverage the employee has. If the type of Coverage is 'Other' then the user will be prompted to enter a description for that coverage in field, EMP RETIREMENT COVERAGE DESC (#61). This field will be used for the CA1 and CA2.
61emp retirement coverage descCA;5FREE TEXTThis field will need to be answered if the response to EMP RETIREMENT COVERAGE (field #60) is 'OTHER'. The response to this field should be a description of the type of other retirement coverage the employee has.
62noi codeCA;3POINTER2263.3Enter the NOI Code from the ASISTS DOL NATURE OF INJURY CODE Table that best describes the Injury/Illness. This field is required prior to the electronic transmission of the CA1/CA2.
63pay plan0;13FREE TEXTThis is the employees Pay Plan. This field is the Type of Pay used in the transmission of CA1/CA2 claims to DOL (Department of Labor).
66date transmitted to wcmisCA;6DATE-TIMEThis is the date that the completed CA1 or CA2 claim was electronically transmitted to the Austin Automation Center (AAC). A Workers Compensation employee must verify the record prior to it being eligible for sending.
67transmit to wcmisWCES;1POINTER200This is the name of the Worker's Compensation employee who has signed the CA1 or CA2 signifying that the claim is complete and is ready to be transmitted to the Austin Automation Center (AAC).
68wc electronic signatureWCES;2FREE TEXTThis is the electronic signature of the Worker's Compensation employee who has approved the CA1/CA2 claim for electronic transmission to DOL (Department of Labor).
69wc date of signatureWCES;3DATE-TIMEThis is the Date that the Worker's Compensation employee signed the CA1/CA2 claim, approving the electronic transmission to DOL (Department of Labor).
70owcp chargeback codeCA;2POINTER2263.6This is the OWCP Chargeback code required by DOL (Department of Labor) for the electronic submission of a CA1/CA2 claim.
71employee bill of rights ok(+)0;14BOOLEANY:Yes
N:No
Indicate your reading and understanding of the Employee Bill of Rights. If you do not understand the Bill of Rights, select No, and contact your facility's Workers Compensation representative for assistance.
72employee consent(+)0;15BOOLEANY:Yes
N:No
If it is acceptable with you to allow the local bargaining unit to review the details of your case, select Yes, otherwise select No, and the details of your case WILL NOT be provided to the local bargaining unit. This review is for accident and occupational illness tracking purposes only.
73owcp district office0;16POINTER2262.1This is the OWCP District Office that the CA1/CA2 claim will be forwarded to upon completion of the claim.
74validation codeCA;7NUMERICThis field contains the validation code for the verification for the Employees electronic signature.
75validation versionCA;9NUMERICThis field contains the version number used to encode the Employee's Electronic Signature Code.
76name of safety officerWCSE;1POINTER200This is the name of the Safety Officer who is giving their approval that the Workers' Compensation personnel can electronically sign for the employee. This is because the employee is not able to sign for themselves.
77safety officer elec. signWCSE;2FREE TEXTThis is the electronic signature of the Safety Officer who is approving the Workers' Compensation personnel to sign electronically for the employee
78safety off. elec. sign dateWCSE;3DATE-TIMEThis is the date that the Safety Officer electronically signed the claim giving their approval that the Workers' Compensation personnel could electronically sign the claim for the employee.
79employee health nameWCSE;4POINTER200This is the name of the Employee Health representative who is giving their approval for the Workers' Compensation personnel to electronically sign the claim for the employee.
80emp health elect. signatureWCSE;5FREE TEXTThis is the electronic signature of the Employee Health representative who is giving their approval that the Workers' Compensation personnel may electronically sign the claim for the employee. This is because the employee is not able to electronically sign for themself.
81emp health elect sign dateWCSE;6DATE-TIMEThis is the date that the Employee Health Representative electronically signed the claim giving their approval that the Workers' Compensation personnel could electronically sign the claim for the employee.
82brand2162B;10POINTER2262.3This is the manufacturer of the device that was being used at the time the incident occurred.
83device size2162B;11POINTER2262.2Enter the DEVICE SIZE of the object that caused the injury.
84safety characteristics2162B;12POINTER2261.9Enter the appropriate ENGINEERED SAFETY CHARACTERISTICS.
85safety device not used2162S;1FREE TEXTEnter the reason that a safety device was not used during this incident.
86service0;17POINTER49This is the individual's service area at the time of the incident.
87inj prior to safe dev engaged2162B;13BOOLEANY:Yes
N:No
This field will indicate whether the safety device on the object that caused the injury engaged before the injury occurred.
88include on osha log2162B;14BOOLEANY:Yes
N:No
AEThis field will indicate whether the ASISTS case filed should appear on the Log of Federal Occupational Injuries and Illnesses. A Yes response will indicate to include the claim, a No response will exclude it from the report.
89fatality2162A;22BOOLEANY:Yes
N:No
This field will indicate whether the incident that is being reported on this claim resulted in a fatality. A Yes response will indicate that a fatality resulted, a No response will indicate that a fatality did not occur.
90date/time stub created0;20DATE-TIMEThis field will capture the Date and Time that the initial Stub record (Create Accident/Illness Report) was filed in the system.
95incident outcomeOUTC;0MULTIPLE2260.095This subfile contains information regarding the employees ability to work as a result of the incident.
100home phone numberCA1A;1FREE TEXTThis is the home phone number of the person involved in the incident. Enter the Area Code and number separated by hyphens or spaces. E.g., 123-122-3456 or 123 122 3456 (Injury)
101grade/level date of injuryCA1A;2FREE TEXTThis is the employee's grade/level at the time of the injury. (Injury)
102step as of date of injuryCA1A;3FREE TEXTThis is the employee's step at the time of the injury. (Injury)
103employee street addressCA1A;4FREE TEXTThis is the employee's street address. (Injury)
104employee city addressCA1A;5FREE TEXTThis is the city where the employee lives. (Injury)
105employee state addressCA1A;6POINTER5This is the employee's state address. (Injury)
106employee zip codeCA1A;7FREE TEXTThis is the employee's Zip code. (Injury)
107dependentsCA1A;8SET OF CODES1:Wife, Husband
2:Children under 18
3:Other
4:Wife, Husband + Children under 18
5:Wife, Husband + Other
6:Children under 18 + Other
7:Wife, Husband + Children under 18 + Other
These are the employee's dependents. (Injury)
108place where injury occurredCA1A;9FREE TEXTThis is a short description of where the injury occurred, e.g., 2nd floor, x-ray, cafeteria, etc. (Injury)
109date/time injury occurredCA1A;10DATE-TIMEThis is the date and time the injury occurred. (Injury)
110date of this noticeCA1A;11DATE-TIMEThis is the date the employee completed the Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation (CA-1). (Injury)
111occupationCA1A;12FREE TEXTThis is a short description of the employee's occupation. (Injury)
112cause of injuryCA1B;1FREE TEXTThis is a short description of what happened and why. (Injury)
113nature of injuryCA1C;1FREE TEXTThis is a description of the injury and the part of the body affected, e.g., fracture of left leg. (Injury)
114request pay or leaveCA1A;13SET OF CODESCOP:Continuation of regular pay
L:Sick and/or annual leave
This is the employee's choice of either continuing regular pay (COP) or taking sick or annual leave (L). If you (the employee) are disabled for work as a result of this injury and file CA-1 within thirty days of the injury, you are entitled to receive continuation of pay (COP) from your employing agency. COP is paid for up to 45 days of disability, and is not charged against sick or annual leave. You may elect sick or annual leave if you wish, but compensation from OWCP may not be claimed during the 45 days of COP entitlement. (You may not claim compensation to repurchase leave used during this period.) Also, if you change your election within one year, the agency is obliged to convert past periods of leave to COP, which qualify. (Injury)
115name of witnessCA1D;1FREE TEXTThis is the name of the person who witnessed the incident. (Injury)
116witness addressCA1D;2FREE TEXT This is the street address of the witness. Form CA-1 item 16.
116.1witness cityCA1D;4FREE TEXT This is the city address of the witness. Form CA-1 item 16.
116.2witness stateCA1D;5POINTER5 This is the state address of the witness. Form CA-1 item 16.
116.3witness zip codeCA1D;6FREE TEXT This is the zip code of the witness. Form CA-1 item 16.
117date of witness signatureCA1D;3DATE-TIMEThis is the date the witness signed the statement of witness on the CA-1.
118statement of witnessCA1E;0WORD-PROCESSINGThis is the statement of the witness that describes what the witness saw, heard, or knows about the injury.
119name of employeeCA1ES;1POINTER200This is the name of the employee injured during the incident. (Injury)
120employee elect. signatureCA1ES;2FREE TEXTThis is the electronic signature of the employee. (Injury)
121employee date of signatureCA1ES;3DATE-TIMEThis is the date the employee electronically signed his/her statement. (Injury)
122occupation codeCA1B;2FREE TEXTThis is the employee's occupation code.
123type codeCA1B;3POINTER2263This is the type code for this injury. It stands for the action and is used along with the source code which stands for the object or substance to form a brief description of how the incident occurred. (Injury)
124source codeCA1B;4POINTER2263.1This is the source code for this injury. It stands for the object or substance and is used along with the type code, which stands for the action, to form a brief description of how the incident occurred. (Injury)
125witness nameCA1W;0MULTIPLE2260.0125This is the name of the person who witnessed the incident and is willing to provide their name, address and a statement describing what occurred. (Injury)
126cause of injury codeCA;1POINTER2263.2The Cause of Injury Code that best matches the Cause of Injury description entered by the Claimant. This field is required prior to the electronic transmission of the CA1/CA2 to DOL (Department of Labor).
130agency nameCA1F;1FREE TEXTThis is the name of the reporting agency (office) to which correspondence from OWCP should be sent. (Injury)
131agency addressCA1F;2FREE TEXTThis is the street address of the reporting agency. (Injury)
132agency cityCA1F;3FREE TEXTThis is the city address of the reporting agency. (Injury)
133agency stateCA1F;4POINTER5This is the state address of the reporting agency. (Injury)
134agency zip codeCA1F;5FREE TEXTThis is the Zip code for the reporting agency. (Injury)
135owcp codeCA1F;6FREE TEXTThis is a four digit (or four digit plus two letter) code used by OWCP to identify the employing agency. The proper code may be obtained from your Human Resources Management or compensation office, or by contacting OWCP. (Injury)
136osha site codeCA1F;7FREE TEXTThis is the Occupational Safety and Health Administration (OSHA) Site Code for the reporting agency. (Injury)
138regular hrs from timeCA1F;9FREE TEXTAt the time of the incident, this is the employee's regular working start time. (Injury)
139regular hrs to timeCA1F;10FREE TEXTAt the time of the incident, this is the employee's regular working stop time. (Injury)
140regular work scheduleCA1F;11FREE TEXTAt the time of the incident, this was the work schedule for the employee. Examples: For Monday through Friday, enter 2-6 For Sunday, Wednesday through Saturday, enter 1,4-7 or 1,4,5,6,7 (Injury)
141date of injuryCA1F;12DATE-TIMEThis is the date the employee was injured. (Injury)
142date/time work stoppedCA1F;13DATE-TIMEThis is the date and time the employee stopped work due to the injury. (Injury)
143date pay stoppedCA1G;1DATE-TIMEThis is the date the employee's pay stopped. (Injury)
144date 45 day period beganCA1G;2DATE-TIMEThis is the date the 45 day period began for COP. (Injury)
145date/time returned to workCA1G;3DATE-TIMEThis is the date and time the employee returned to work. (Injury)
146injured performing dutyCA1G;4BOOLEANN:No
Y:Yes
This is a Yes/No statement of whether the employee was injured while in the performance of duty. (Injury)
147not injured performing jobCA1G;5FREE TEXTThis is short description of why the injury was not incurred while the employee was in performance of duty. (Injury)
148injury caused by employeeCA1G;6BOOLEANN:No
Y:Yes
The injury was caused (Yes) or not caused (No) by the employee's willful misconduct, intoxication, or intent to injure self or another. (Injury)
149caused by employee explainCA1G;7FREE TEXTThis is a short explanation of why the employee caused the injury through willful misconduct, intoxication, or intent to injure. (Injury)
150injury caused by 3rd partyCA1G;8BOOLEANN:No
Y:Yes
The injury was caused (Yes) or was not caused (No) by a third party. (Injury)
1513rd party nameCA1H;1FREE TEXTIf the injury was caused by someone other than the injured employee, this is the name of that third party. (Injury)
1523rd party addressCA1H;2FREE TEXTThis is the street address of the third party. (Injury)
1533rd party cityCA1H;3FREE TEXTThis is the city address of the third party. (Injury)
1543rd party stateCA1H;4POINTER5This is the state address of the third party. (Injury)
1553rd party zip codeCA1H;5FREE TEXTThis is the third party's Zip code. (Injury)
156physician nameCA1I;1FREE TEXTThis is the name of the physician who first provided medical care to the employee. (Injury)
157physician addressCA1I;2FREE TEXTThis is the physician's street address. (Injury)
158physician cityCA1I;3FREE TEXTThis is the physician's city address. (Injury)
159physician stateCA1I;4POINTER5This is the physician's state address. (Injury)
160physician zip codeCA1I;5FREE TEXTThis is the physician's Zip code. (Injury)
161first date medical careCA1I;6DATE-TIMEThis is the first date the employee received medical care for the injury. (Injury)
162disabled for workCA1I;7BOOLEANN:No
Y:Yes
This states whether or not medical reports show employee is disabled for work. (Injury)
163supervisor agree/disagreeCA1I;8BOOLEANY:Yes
N:No
The supervisor's knowledge of the facts about this injury agree (Yes) or disagree (No) with statements of the employee and/or witness. (Injury)
164supervisor not agree explainCA1J;0WORD-PROCESSINGThis is why the supervisor does not agree with the statements of the employee and/or witness regarding the injury. (Injury)
165reason agency controverts copCA1K;0WORD-PROCESSINGThis is a detailed reason why the employing agency controverts continuation of pay. (Injury)
165.1agency controvertCA1I;10BOOLEANY:YES
N:NO
This field will be used by the Worker's Compensation Specialist to indicate whether the Agency controverts the claim. (Injury)
165.2agency disputeCA1I;11BOOLEANY:YES
N:NO
This field will be completed by the Worker's Compensation specialist to indicate whether the Agency disputes the claim. (Injury)
166pay rate dollarCA1L;1NUMERICThis is the amount of the pay rate when the employee stopped work. (Injury)
167pay rate perCA1L;2SET OF CODES1:WEEKLY
2:BI-WEEKLY
6:DAILY
H:HOURLY
A:ANNUAL
This is the rate at which the employee was receiving the pay when the employee stopped work. (Injury)
168supervisor exceptionsCA1L;3FREE TEXTThis is the supervisor's exception to any of the information provided on the CA-1. (Injury)
169name of supervisorCA1ES;4POINTER200This is the name of the supervisor completing the supervisor's portion of the CA-1. (Injury)
170supervisor elect. signatureCA1ES;5FREE TEXTThis is the supervisor's electronic signature. (Injury)
171supervisor date of signatureCA1ES;6DATE-TIMEThis is the date the supervisor signed the CA-1. (Injury)
172supervisor titleCA1L;4FREE TEXTThis is the supervisor's title. (Injury)
173supervisor office phoneCA1L;5FREE TEXTThis is the supervisor's office phone number. (Injury)
173.1supervisor phone extCA1L;8FREE TEXTThis field is available so that the Supervisor's office phone extension can be entered for a CA1. (Injury)
174filing instructionsCA1L;6SET OF CODES1:No lost time and no medical expenses
2:No lost time, medical expenses incurred
3:Lost time covered by leave LWOP or COP
4:First aid injury
These are the filing instructions for the CA-1: 1. No lost time and no medical expense: Place this form in employee's medical folder(SF-66-D). 2. No lost time, medical expense incurred or expected: forward this form to OWCP. 3. Lost time covered by leave, LWOP, or COP: forward this form to OWCP. 4. First Aid Injury. (Injury)
175date notice receivedCA1L;7DATE-TIMEThis is the date the supervisor received notice that the employee filed a CA-1. (Injury)
176employee duty stationCA1M;1FREE TEXTThis is the station where the employee works. (Injury)
177duty station addressCA1M;2FREE TEXTThis is the duty station street address. (Injury)
178duty station cityCA1M;3FREE TEXTThis is the duty station city address. (Injury)
179duty station stateCA1M;4POINTER5This is the duty station state address. (Injury)
180duty station zip codeCA1M;5FREE TEXTThis is the duty station's Zip code. (Injury)
181zip code where injury occurredCA1A;14FREE TEXTThis is the Zip Code of the location where the injury occurred and is used on the CA1 only. (Injury)
182physician titleCA1I;9POINTER2263.5This is the appropriate title for the Physician who first saw the employee This field is used for CA1 claims. (Injury)
183injury occurred addressCA1N;1FREE TEXTThis is the street address where the injury occurred. Generally, this will be the same address as the duty station street address. (Injury)
184injury occurred cityCA1N;2FREE TEXTThis is the City portion of the address where the injury occurred. Generally, this will be the same as the individual's duty station city. (Injury)
185injury occurred stateCA1N;3POINTER5This is the State portion of the address where the injury occurred. Generally, this will be the same as the individual's duty station state. (Injury)
199worker's comp editCA;8BOOLEANY:Yes
N:No
This field will indicate whether one of the following fields was edited by the Worker's Compensation Personnel in preparation for sending the claim to DOL (Department of Labor): INJURED PERFORMING DUTY (#146), NOT INJURED PERFORMING DUTY (#147), INJURY CAUSED BY EMPLOYEE (#148), INJURY CAUSED BY EMPLOYEE EXPLAIN (#149), SUPERVISOR AGREE/DISAGREE (#163), SUPERVISOR NOT AGREE EXPLAIN (#164), and REASON AGENCY CONTROVERTS COP (#165). (Injury)
200home phone numberCA2A;1FREE TEXTThis is the home phone number of the person involved in this incident. Enter the Area Code and number separated by hyphens or spaces. E.g., 123-122-3456 or 123 122 3456 (Illness/disease)
201grade as of last exposureCA2A;2FREE TEXTThis is the employee's grade as of the date of last exposure. (Illness/disease)
202step as of date of ill.CA2A;3FREE TEXTThis is the employee's step as of date of last exposure. (Illness/disease)
203employee street addressCA2A;4FREE TEXTThis is the employee's street address. (Illness/disease)
204employee city addressCA2A;5FREE TEXTThis is the employee's city address. (Illness/disease)
205employee state addressCA2A;6POINTER5This is the employee's state address. (Illness/disease)
206employee zip codeCA2A;7FREE TEXTThis is the employee's Zip code. (Illness/disease)
207dependentsCA2A;8SET OF CODES1:Wife, Husband
2:Children under 18
3:Other
4:Wife, Husband + Children under 18
5:Wife, Husband + Other
6:Children under 18 + Other
7:Wife, Husband + Children under 18 + Other
These are the employee's dependents. (Illness/disease)
208employee occupationCA2A;9FREE TEXTThis is a short description of the employee's occupation. (Illness/disease)
209illness occurred (location)CA2B;1FREE TEXTThis is the location where the employee worked when the disease or illness occurred. (Illness/disease)
210illness occurred addressCA2B;2FREE TEXTThis is the street address of the location where the illness occurred. (Illness/disease)
211illness occurred cityCA2B;3FREE TEXTThis is the city of the location where the illness occurred. (Illness/disease)
212illness occurred stateCA2B;4POINTER5This is the location's state where the illness occurred. (Illness/disease)
213illness occurred zip codeCA2B;5FREE TEXTThis is the location's zip code where the illness occurred. (Illness/disease)
214date first aware of illnessCA2B;6DATE-TIMEThis is the date you (the employee) were first aware of the disease or illness. (Illness/disease)
215date first realized causeCA2B;7DATE-TIMEThis is the date you (the employee) first realized the disease or illness was caused by your employment. (Illness/disease)
216relationship of illness to empCA2C;0WORD-PROCESSING
217nature of disease/illnessCA2D;0WORD-PROCESSINGThis is a complete description of the disease or illness. Specify the left or right side if applicable (e.g., rash on left leg; carpal tunnel syndrome, right wrist). (Illness/disease)
218claim not filedCA2E;0WORD-PROCESSINGIf this notice and claim was not filed with the employing agency within 30 days after the date you first realized the disease or illness was caused or aggravated by your employment, this is your (the employee's) explanation of the reason for the delay. (Illness/disease)
219employee statement delayedCA2F;0WORD-PROCESSINGIf a separate narrative statement containing the following information will not be submitted with this form, explain the reason for the delay: a) A detailed history of the disease or illness from the date it started. b) Complete details of the conditions of employment which are believed to be responsible for the disease or illness. c) A description of specific exposures to substances or stressful conditions causing the disease or illness, including locations where exposure or stress occurred, as well as, the number of hours per day and days of week of such exposure or stress. d) Identification of the part of the body affected. (If disability is due to a heart condition, give complete details of all activities for one week prior to the attack with particular attention to the final 24 hours of such period.) e) A statement as to whether the employee ever suffered a similar condition. If so, provide full details of onset, history, and medical care received, along with names and addresses of physicians rendering treatment. (Illness/disease)
220medical report delayedCA2G;0WORD-PROCESSINGIf medical reports containing the information listed here are not submitted with this form, explain the reason for the delay. a) Dates of examination or treatment. b) History given to the physician by the employee. c) Detailed description of the physician's findings. d) Results of x-rays, laboratory tests, etc. e) Diagnosis. f) Clinical course of treatment. g) Physician's opinion as to whether the disease or illness was caused or aggravated by the employment, along with an explanation of the basis for this opinion. (Medical reports that do not explain the basis for the physician's opinion are given very little weight in adjudicating the claim.) (Illness/disease)
221name of employeeCA2ES;1POINTER200
222employee elect. signatureCA2ES;2FREE TEXTThis is your (the employee's) electronic signature. (Illness/disease)
223date of employee signatureCA2ES;3DATE-TIMEThis is the date you (the employee) signed the notice/claim for compensation. (Illness/disease)
224occupationCA2B;8FREE TEXT
225owcp use noi codeCA2B;9FREE TEXT
226type codeCA2B;10POINTER2263This is the Type code for this claim. The Type code stands for an action and is associated with the Source code which is an object or substance. Both are used to summarize the incident. (Illness/disease)
227source codeCA2B;11POINTER2263.1This is the Source code for this claim. It is the object or substance that is used along with the Type code which is an action. Both are used to summarize the incident. (Illness/disease)
230agency nameCA2H;1FREE TEXTThis is the agency name of the station reporting the incident. (Illness/disease)
231agency addressCA2H;2FREE TEXTThis is the street address of the agency reporting the incident. (Illness/disease)
232agency cityCA2H;3FREE TEXTThis is the city address of the agency reporting the incident. (Illness/disease)
233agency stateCA2H;4POINTER5This is the state address of the agency reporting the incident. (Illness/disease)
234agency zip codeCA2H;5FREE TEXTThis is the Zip code of the agency reporting the incident. (Illness/disease)
235owcp agency codeCA2H;6FREE TEXTThis is a four digit (or four digit plus two letter) code used by the OWCP to identify the employing agency. The proper code may be obtained from your personnel or compensation office, or by contacting OWCP. (Illness/disease)
236osha site codeCA2H;7FREE TEXTThis is the Occupational Safety and Health Administration (OSHA) Site code for the reporting agency. (Illness/disease)
237employee duty stationCA2I;1FREE TEXTThis is the agency/site where the employee actually works. (Illness/disease)
238duty station addressCA2I;2FREE TEXTThis is the address of the site where the employee works. (Illness/disease)
239duty station cityCA2I;3FREE TEXTThis is the city where the employee works. (Illness/disease)
240duty station stateCA2I;4POINTER5This is the state address for where the employee works. (Illness/disease)
241duty station zip codeCA2I;5FREE TEXTThis is the Zip code for the employee's duty station. (Illness/disease)
242regular hrs from timeCA2I;6FREE TEXTThis the time the employee generally starts work. (Illness/disease)
243regular hrs to timeCA2I;7FREE TEXTThis is the time the employee generally stops work. (Illness/disease)
244regular work scheduleCA2I;8FREE TEXTAt the time of the incident, this was the work schedule for the employee. Examples: For Monday through Friday, enter 2-6 For Sunday, Wednesday through Saturday, enter 1,4-7 or 1,4,5,6,7 (Illness/disease)
245name of physicianCA2J;1FREE TEXTThis is the name of the physician first providing medical care for the employee. (Illness/disease)
246physician addressCA2J;2FREE TEXTThis is the street address of the physician providing medical care. (Illness/disease)
247physician cityCA2J;3FREE TEXTThis is the city address of the physician providing medical care. (Illness/disease)
248physician stateCA2J;4POINTER5This is the state address of the physician providing medical care. (Illness/disease)
249physician zip codeCA2J;5FREE TEXTThis is the Zip code for the physician's address. (Illness/disease)
250first date medical careCA2J;6DATE-TIMEThis is the date the employee first received medical care for the condition. (Illness/disease)
251disabled for workCA2J;7BOOLEANY:Yes
N:No
This states whether or not (Yes or No) the medical reports show that the employee is disabled for work. (Illness/disease)
252date notice receivedCA2J;8DATE-TIMEThis is the date the employee first reported the condition to the supervisor. (Illness/disease)
253date/time work stoppedCA2J;9DATE-TIMEThis is the date and time the employee stopped work due to the condition. (Illness/disease)
254date/time pay stoppedCA2J;10DATE-TIMEThis is the date and time the employee's pay stopped. (Illness/disease)
255date of last exposureCA2J;11DATE-TIMEThis is the date the employee was last exposed to conditions alleged to have caused the disease or illness. (Illness/disease)
256date/time returned to workCA2J;12DATE-TIMEThis is the date and time the employee returned to work. (Illness/disease)
257work duty changedCA2K;0WORD-PROCESSINGIf the work assignment changed when the employee returned to work, this is a description of the employee's new duties. (Illness/disease)
258injury caused by 3rd partyCA2L;1BOOLEANN:No
Y:Yes
This states whether or not (Yes or No) the injury was caused by a third party. (Illness/disease)
2593rd party nameCA2L;2FREE TEXTThis is the name of the third party causing the injury. (Illness/disease)
2603rd party addressCA2L;3FREE TEXTThis is the street address of the third party causing the injury. (Illness/disease)
2613rd party cityCA2L;4FREE TEXTThis is the city address of the third party causing the injury. (Illness/disease)
2623rd party stateCA2L;5POINTER5This is the state address of the third party causing the injury. (Illness/disease)
2633rd party zip codeCA2L;6FREE TEXTThis is the Zip code address for the third party that caused the injury. (Illness/disease)
264supervisor exceptionCA2L;7FREE TEXTIf the supervisor has any exceptions to the information provided on the claim, they are stated here. (Illness/disease)
265name of supervisorCA2ES;4POINTER200This is the name of the supervisor completing this notice/claim. (Illness/disease)
266supervisor elect. signatureCA2ES;5FREE TEXTThis is the electronic signature of the supervisor. (Illness/disease)
267supervisor date of signatureCA2ES;6DATE-TIMEThis is the date the supervisor signs the notice/claim. (Illness/disease)
268supervisor titleCA2H;8FREE TEXTThis is the title of the supervisor signing the notice/claim. (Illness/disease)
269supervisor phoneCA2H;9FREE TEXTThis is the supervisor's office phone number. (Illness/disease)
269.1supervisor phone extCA2H;10FREE TEXTThis field is available so that the Supervisor's office phone extension can be entered for a CA2. (Illness/disease)
270physician titleCA2J;13POINTER2263.5This is the appropriate title for the Physician who first saw the employee. This is the field to be used for a CA2 claim. (Illness/disease)
303veteranDUAL;1BOOLEANY:Yes
N:No
This is a Yes/No field that will indicate if the employee is also a veteran.
304receive veteran benefitsDUAL;2BOOLEANY:Yes
N:No
This is a Yes/No field that will indicate whether the employee filing the CA-7 claim is receiving military benefits.
305pending disability claimDUAL;3BOOLEANY:Yes
N:No
This is a Yes/No field that will indicate whether the user has a claim pending review.
306vba numberDUAL;4FREE TEXTIf the employee is a veteran, this field will contain their veteran's benefit number (VBA number).
307military claim body partsDUAL1;1FREE TEXTThis field will contain the parts of the employee's body that are involved in the claim.
308condition accepted in claimDUAL;6FREE TEXTThis field contains the condition that the employee accepted in the claim.
309emp name of dual benefitDUAL;7POINTER200This field will contain the pointer to the New Person file (#200) of the employee who signed the Dual Benefits Form.
310emp dual benefits e-signatureDUAL;8FREE TEXTThis field will contain the employee's encrypted electronic signature.
311emp dual benefit sign dateDUAL;9DATE-TIMEThis field will contain the date that the employee electronically signed the Dual Benefit Form.
312wc name for dual benefitDUAL;10POINTER200This field contains the pointer to the New Person file (#200) for the Workers' Compensation specialist who electronically signed the Dual Benefits Form.
313wc dual benefits e-signatureDUAL;11FREE TEXTThis field contains the electronic signature for the Workers' Compensation Specialist's who signed the Dual Benefits Form.
314wc dual benefits sign dateDUAL;12DATE-TIMEThis field contains the date that the Workers' Compensation Specialist electronically signed the Dual Benefits Form.
330owcp suffixCA;17FREE TEXTThis field contains a 2 character extension for the OWCP Chargeback code. It provides flexibility to the facility to further identify the station although the extension is not required.
331owcp code (6 character)CA;18FREE TEXTThis field combines the OWCP Chargeback code (table driven - ASISTS OWCP CHARGEBACK CODES File (#2263.6) with the 2 character, free text OWCP suffix for the purpose of transmitting the claim to the Department of Labor and running reports based on the further chargeback code designation.
332agency controverts codeCA1I;12POINTER2262.4This field contains the reason for controverts code that must be used when a case has a reason for controvert code entered.
333date of death2162A;23DATE-TIMEIf the incident resulted in a fatality, this field contains the date of the death.
334illness type2162B;15SET OF CODES2:Skin disorder
3:Respiratory condition
4:Poisoning
5:Hearing loss
6:All other illnesses
This is the category of the Illness or Disease for the incident and is used in completing the OSHA 300 Log.
335time work began0;22FREE TEXTThis is the time that the individual involved in the incident began work on the date of the incident.
336hire date2162A;24DATE-TIMEThis is the date (Service Computation Date) that the individual involved in the incident first began working.
337privacy case2162D;10BOOLEANY:Yes
N:No
This field indicates whether the incident should be treated as a 'privacy case'. If so, restrictions on how the name is displayed are in place.
338non va er treatment rcvd2162D;11BOOLEANY:Yes
N:No
This Yes/No field is used to indicate whether the individual involved in the incident was treated at a non-VA emergency treatment center.
339hospitalized as inpatient2162D;12BOOLEANY:Yes
N:No
This Yes/No field is used to indicate if the individual involved in the incident was admitted to as an inpatient to a medical center.
340treating physician2162D;13FREE TEXTThis field contains the name of the physician who first treated the individual involved in the incident.
341treated at different facility2162L;1BOOLEANY:Yes
N:No
This Yes/No field is used to indicate whether the individual involved in the incident was treated at a non-VA treatment center.
342other facility name2162L;2FREE TEXTThis is the name of the facility if the individual involved in the incident was treated at a different facility.
343other facility street2162L;3FREE TEXTThis is the street address of the facility if the individual involved in the incident was treated at a different facility.
344other facility city2162L;4FREE TEXTThis is the city portion of the address of the facility if the individual involved in the incident was treated at a different facility.
345other facility state2162L;5POINTER5This is the state portion of the address of the facility if the individual involved in the incident was treated at a different facility.
346other facility zip2162L;6FREE TEXTThis is the zip code portion of the address of the facility if the individual involved in the incident was treated at a different facility.
347reason for dispute codeCA1I;13POINTER2262.8This is the high level reason that the agency is disputing the CA-1.
348location detail2162B;16FREE TEXTThis field contains the optional location detail where the injury occurred.
349loss of consciousness(+)2162L;7BOOLEANY:Yes
N:No
This field indicates whether the individual lost consciousness as a result of the incident or not.
350prescription strgth meds given(+)2162L;8SET OF CODESY:Yes
N:No
U:Unknown
This field indicates if the individual involved in the incident was given or ordered prescription strength medication.
351non-script meds at script dose(+)2162L;9SET OF CODESY:Yes
N:No
U:Unknown
This field will indicate whether the individual involved in the incident was given or ordered non-prescription medication as prescription strength. (such as Motrin).
352initial return to work status2162L;10SET OF CODESF:FULL DUTY
A:DAYS AWAY WORK
J:Job Transfer/Restriction
This field will indicate the initial return to work status of the individual involved in the incident. This work status may change.
353dual refusedDUAL;5BOOLEANY:YES
N:NO
354weather factor2162M;1POINTER2261.21This field contains the weather condition at the time of the incident.
355source of incident2162M;2POINTER2261.22This field is the most relevant source of the Incident.
356cause of incident2162M;3SET OF CODESAA:Equipment or Environment
BA:Person
CA:Nature
FA:Cause Unknown
This is the most probable cause of the accident
357additional cause of incident2162M;4SET OF CODESAA:Equipment or Environment
BA:Person
CA:Nature
ZZ:No additional Cause
This field will contain the secondary cause of the incident.
358preventive method2162M;5POINTER2261.24This field contains the most likely way to have prevented the incident.
359status of corrective action2162M;6SET OF CODESA:Taken
B:Requested and Anticipated
C:Requested
D:None
This field contains the status of any recommended corrective action to be taken.
360severity of injury2162M;7SET OF CODES1:No Treatment Required
2:First Aid Only
3:Medical Treatment
4:Disabling Injury
5:Fatality
This field indicates how devastating the injury was to the individual.
384osha 300 column f2162R;1FREE TEXTThis field will contain a brief description of the incident that will be used to populate column F of the OSHA 300 Log report.

Referenced by 1 types

  1. ASISTS COMPENSATION CLAIM (CA7) (2264) -- asists record