6.800.1  Workers’ Compensation Program

6.800.1.1  (02-25-2011)
Purpose and Content

  1. This section explains all general aspects of the Workers’ Compensation Program as it applies to the Internal Revenue Service.

  2. It provides the legal basis and administrative oversight of the program.

  3. This section includes procedures and guidance for processing and managing workers’ compensation claims.

  4. It includes several helpful exhibits which contain sample guides and informational items.

  5. This section is subject to revision as the IRS Workers' Compensation Center (WCC) procedures, Federal Employees' Compensation Act (FECA), and applicable regulations are amended periodically .

  6. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.2  (02-25-2011)
Legal Basis and IRS Program Oversight

  1. The FECA, under the authority of United States Code (5 USC 8101 et. seq.) and the Code of Federal Regulations (20 CFR Part 1 and Part 10) provides compensation benefits to civilian employees of the United States for disability due to personal injury or disease sustained while in the performance of duty. The FECA also provides for the payment of benefits to dependents if a work-related injury or disease causes an employee’s death. The FECA is intended to be remedial in nature, and proceedings under it are non-adversarial.

  2. Benefits provided under the FECA constitute the sole remedy against the United States for work-related injury, illness or death. A Federal employee or surviving dependent is not entitled to sue the United States or recover damages for such injury or death under any other statute. The Department of Labor (DOL) Secretary has delegated the responsibility for administration and implementation of Chapter 5 of the FECA to the Director, Office of Workers’ Compensation Programs (OWCP). Therefore, the DOL's OWCP alone determines whether the employee is entitled to benefits and compensation under the FECA.

  3. Under the Secretary of the Treasury's authority, IRS has designated the Workers' Compensation Center (WCC) as the agency's official liaison with the OWCP. The WCC is responsible for policy development and program administration.

  4. The FECA mandates that all initial claims, whether via electronic filing or on paper forms (CA-1 and CA-2), must be submitted to the OWCP no later than 10 workdays from the agency’s (IRS) receipt of the claim. The agency’s receipt date is the date the manager receives the signed claim summary sheet or claim form from the injured worker. Forms CA-7 for wage loss compensation and/or Forms CA-2a, Notice of Recurrence, are to be submitted within 5 workdays of the agency’s receipt.

  5. The WCC provides all workers’ compensation services for the IRS through a variety of state-of-the-art, user-friendly modalities. The program uses automation and telecommunications systems to ensure information access and services for all employees and managers Servicewide. All personnel responsible for administering FECA ensure the protection of claimants’ rights and benefit entitlements.

  6. The WCC is designed to increase the effectiveness of the IRS Workers’ Compensation Program through program integration and collaboration with all stakeholders to include, but not limited to, Reasonable Accommodations, Employment, Labor Relations, Managers, Business Operating Division/Principal Office Executives, General Legal Services (GLS), Treasury Inspector General for Tax Administration (TIGTA), and Safety.

  7. Criminal penalties may be imposed for filing a false claim or obstructing the filing of a claim under the FECA. Refer to 18 USC Section 1920 and 18 USC 1922 for criminal penalties associated with filing false claims or obstructing the filing of workers' compensation claims. See Regulations in 20 CFR 10.16 for additional information on criminal and civil penalties and assessments under the Program Fraud and Civil Remedies Act of 1986 (PFCRA), 31 USC 3801-12 and 29 CFR, part 22. See IRM 6.800.1.14. Managers' Initial Claims Management paragraph (4).

6.800.1.3  (02-25-2011)
Responsibilities of Employees

  1. The responsibilities of all employees are as follows:

    1. Report all job-related injuries immediately to your manager.

    2. If desired, file a claim for Workers' Compensation benefits as specified in IRM 6.800.1.6 Process Overview and Claim Forms. It is preferred that you e-file your claim using the Safety and Health Information Management System (SHIMS). You must notify your manager of your claim.

    3. If necessary, seek medical attention immediately.

    4. Provide all required information, including medical and duty status documentation. Advise your physician(s) that light/limited duty is available.

    5. Keep management informed of your medical and duty status and promptly report any changes in medical or duty status.

    6. Adhere to medical restrictions prescribed by your attending physician(s) while on and off duty.

    7. Return to work as soon as possible when medical documentation indicates you are no longer totally disabled.

    8. Cooperate with management to identify suitable work assignments to facilitate return to gainful employment and request assistance from the Reasonable Accommodations Coordinator if necessary.

    9. Review all benefit statements to ensure that:

    • federal health and life insurance premiums are properly deducted from OWCP compensation pay,

    • federal health and life insurance premiums are paid during periods of OWCP-LWOP to ensure continued coverage, and

    • any overpayments made regarding compensation pay are detected and reported.

  2. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.4  (02-25-2011)
Responsibilities of Managers

  1. The responsibilities of all managers are as follows:

    1. Assist injured employees to receive prompt and appropriate medical attention.

    2. Properly complete and timely submit appropriate injury forms.

    3. Have the following forms available:

      • CA-1, Federal Employees' Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation

      • CA-2, Notice of Occupational Disease and Claim for Compensation

      • CA-16, Authorization for Examination and/or Treatment

      • CA-17, Duty Status Report

      Most workers' compensation forms are available for printing on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section. Forms are also available on the Department of Labor (OWCP) website at http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm. Form CA-16 may be ordered from the National Distribution Center or obtained from the WCC.

    4. Investigate the circumstances of the claimed injury/disease to determine the time, place, and cause/manner prior to completing the Supervisor's Report.

    5. Be advised that OWCP will accept the claimant’s statements as factual and will assume that the agency fully concurs with the claimed injury. If the supervisor's investigation reveals reasons to dispute the validity of the claim, the supervisor must contact the WCC for guidance.

    6. Advise the employee of the availability of light or limited duty. Managers must also remind employees of their obligation to return to work as soon as possible when medical documentation indicates that they are no longer totally disabled.

    7. Advise the employee to keep their manager informed of their medical and duty status.

    8. Managers must monitor the employee’s medical progress and duty status by obtaining periodic medical reports from the employee’s physician. Provide the Duty Status Report, Form CA-17, to the employee for each doctor’s visit. Instruct the employee to return the completed form immediately to you after each visit or immediately upon receipt from the physician.

    9. Work with the WCC in monitoring continuation of pay during the 45-day entitlement period.

    10. Provide or modify jobs or work assignments compatible with the employee's medical limitations. Any work modifications must consider the employee's skill, pay, and grade when providing suitable work assignments.

    11. Initiate a Personnel Action Request (PAR) when an injured employee is carried in an OWCP-LWOP status for 80 hours or more.

    12. The WCC must be notified should it becomes necessary to separate an injured employee who has an open workers' compensation claim. Managers must contact the WCC prior to initiating any separation action.

    13. Managers must provide a copy of the SF-50, Notification of Personnel Action, to the WCC case manager when the employee is separated from IRS for any reason.

  2. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.5  (02-25-2011)
Responsibilities of IRS Workers' Compensation Center

  1. The responsibilities of the IRS Workers' Compensation Center (WCC) are as follows:

    1. Administer the Workers' Compensation Program for the IRS.

    2. Serve as IRS's official liaison with the DOL OWCP.

    3. Advise managers and employees of their responsibilities under the FECA.

    4. Provide case management services to injured workers and their managers to include the following:

      • Process and submit initial claims via electronic transmission to OWCP when appropriate.

      • Review claims and consult with managers to support or controvert/challenge claims when appropriate.

      • Track pending and approved claims, including Continuation of Pay (COP) related cases, to ensure compliance with FECA rules.

      • Monitor approved claims and medical evidence to determine earliest practical return to duty date.

      • Assist managers with their responsibilities to identify and assign suitable work for partially recovered injured workers.

    5. Cooperate with Safety officials and other personnel to identify injury trends.

    6. Receive, review, approve, and monitor leave buy back requests.

    7. Inform and consult with managers regarding their Workers' Compensation responsibilities.

  2. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.6  (02-25-2011)
Process Overview & Claims Forms

  1. Upon notification of a work-related injury/disease, the manager must discuss the situation with the employee and advise them of their right to file a Workers' Compensation Claim. When necessary, managers must be prepared to assist the employee with filing a claim. A claim can be made using the appropriate paper form. It is preferred that employees e-file their claim using the Safety and Health Information Management System (SHIMS) at https://shims.treas.gov/shims/web/MenuClaimant10.htm. Upon notification, the manager must discuss and collect information on how, when, and where the injury/illness took place. Collect the names of any witnesses, if appropriate. Once these facts are obtained, the manager will inspect the location of the incident and the surrounding work area, if possible. At the conclusion of this fact finding, the manager must determine the type of injury and complete the supervisor's portion of the claim using SHIMS. If a computer is not available, the manager must provide their information on the paper form. Most of the forms listed below are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

    1. Form CA-1, Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. This form is for traumatic injury cases only. A traumatic injury is a wound or other condition caused by external forces, including physical stress or strain caused by a specific event or incident, or series of events within a single work shift. The injury is identifiable as to time and place of occurrence and part or function of the body affected. This is the criterion that sets a traumatic injury apart from an occupational disease.

    2. Form CA-2, Notice of Occupational Disease and Claim for Compensation. An occupational disease is produced by systemic infections, continued or repeated stress or strain, exposure to poison fumes, noise, etc., in the work environment over a longer period of time. To qualify as an occupational disease or illness, the injury must be caused by exposure or activities on more than one workday or shift. The OWCP has developed checklists (Forms CA-35 A through H) to assist employees and agency personnel in gathering and submitting material required for adjudication of occupational disease claims.

    3. Form CA-2a, Federal Employee’s Notice of Recurrence of Disability and Claim for Continuation of Pay and Compensation. A recurrence of an injury (traumatic or occupational) is defined as a spontaneous return or increase of disability due to a previously accepted injury/disease, without intervening cause.

    4. Form CA-7, Claim for Compensation on Account of Traumatic Injury or Occupational Disease. This form is used to claim compensation for wages lost due to a work-related traumatic injury after the expiration of COP or when COP is not authorized. The CA-7 is also used for claiming wage loss for occupational disease claims. Generally, a CA-7 should not be filed until the CA-1 or CA-2 claim is approved. The CA-7 is submitted biweekly to claim compensation for wage loss. CA-7s may not be submitted with dates more than seven (7) calendar days in the future. The CA-7 is also used for leave buybacks and schedule award requests. The CA-20, Physician’s Report, is attached to the CA-7. The CA-20 is completed by the attending physician providing supporting medical documentation. It is the injured worker's responsibility to request completion of the CA-20 to provide supporting medical documentation.

    5. Form CA-16, Authorization for Examination and/or Treatment . This form is used to authorize initial medical treatment in traumatic injury cases only. This form allows initial payment of medical bills by OWCP to the provider in accordance with OWCP's medical fee schedule. Managers can order the CA-16 from the National Distribution Center (NDC) or obtain it from the Workers' Compensation Center.

    6. Form CA-35(A-H), Evidence Required in Support of a Claim for Occupational Disease. This form provides information needed by OWCP to adjudicate occupational disease/illness claims.

    7. Form CA-17, Duty Status Report . The manager should provide the CA-17 to the injured employee to document the employee’s duty status (i.e., total disability, return to work with restrictions, or release to full duty).

    8. OWCP-1500 or HCFA-1500, Health Insurance Claim Form. This form is used to request payment for most medical bills. All doctor bills not directly related to a hospital stay must be submitted on the OWCP-1500.

    9. OWCP-04, Uniform Billing Form. This information is required to reimburse healthcare providers for services rendered to injured employees covered under the FECA.

    10. Form OWCP-915, Claimant for Medical Reimbursement . This form is used to claim reimbursement for out of pocket medical expenses pertaining to the treatment of an accepted condition covered by the FECA.

    11. OWCP-957, Medical Travel Refund Request. This form is used to claim reimbursement for medically related travel covered under the FECA.

    12. SF-1199A, Direct Deposit Sign-up Form. This form is used to authorized direct deposit of compensation payments and may be obtained from local financial institutions.

  2. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.7  (02-25-2011)
Traumatic Injury Claim Procedures (Includes Paper Claim Form CA-1 Methods)

  1. A traumatic injury is defined as a wound or other condition of the body caused by external force including stress or strain. The injury must be identifiable as to the time and place of occurrence and the member or function of the body affected. It must be caused by a specific event or incident or series of events or incidents within a SINGLE DAY or WORK SHIFT.

  2. Report all injuries immediately to the WCC by telephone toll-free at 800-234-8323. Be prepared to report all the facts of the injury.

  3. Advise the employee to e-file the claim using SHIMS. If there is no computer available, provide the employee with the appropriate paper form (Form CA-1) to file for workers' compensation benefits. See IRM 6.800.1.6. for information on filing claims.

  4. If e-filing is not an option, the claim must be submitted as a paper claim. After the employee completes the employee's section of the form, it must be submitted to the manager who is responsible for completing the supervisor’s report section of the form. The completed form should then be submitted via fax transmittal to WCC at 804-771-2270 for review. The original signed claim form must be mailed (by overnight delivery) to the WCC within two workdays of receipt from the injured employee. The WCC address is: Internal Revenue Service, Workers' Compensation Center, 400 North 8th Street, Box 78, Richmond, VA 23219-4838.

  5. The injury claim must be completed and transmitted by the WCC to OWCP within 10 working days after the manager receives written notice (claim form) from the employee. Therefore, all claims must be submitted timely to the WCC for forwarding to OWCP within the prescribed timeframes.

  6. The "Receipt of Notice of Injury" must be completed and signed by the supervisor and returned to the employee. A copy must be attached to the original CA-1 and sent to the WCC.

  7. Once the traumatic injury claim (CA-1) has been completed, the manager should advise the employee that they may choose a physician within a reasonable distance of the employee's workplace or residence. OWCP has considered 25 miles from the agency or the employee's home a reasonable distance to travel for medical care. However, if appropriate care is not available within that radius, OWCP may approve appropriate additional mileage. Under FECA law, physicians may also include board certified psychologists, optometrists, and chiropractors (for treatment of manual manipulation of the spine to correct a subluxation, shown by x-ray to exist). Inform the employee that a change of physician can only be authorized by OWCP.

  8. The manager should promptly authorize treatment by giving the employee a properly executed Form CA-16, Authorization for Examination and/or Treatment. The CA-16 should not be issued more than 7 days after the employee’s injury. To be valid, a Form CA-16 must give the full name and address of the physician or medical facility, must be signed and dated by the authorizing official (usually the manager) and must show his or her title and local phone number. In emergencies, when there is no time to complete a Form CA-16, the manager may authorize treatment by telephone and then forward the completed CA-16 to the medical provider within 48 hours. If the employee has already been seen by the physician, the Form CA-16 is generally not issued retroactively. Managers are encouraged to use discretion in issuing this form if an employee has reported an injury several days after the fact, or did not request medical treatment within 24 hours of the injury. The CA-16 obligates the agency to pay for medical treatment for a period of 60 days. Therefore, in cases of a doubtful nature (for example, injury may not be work-related, late reporting of injury by employee), Item 6(B)(2) of the form should be completed authorizing an initial examination only.

  9. The employer will provide an employee who is injured while in work status with a copy of the Publication CA-550, FECA Questions and Answers about the Federal Employees' Compensation Act. Electronic copies of the CA-550 will be available through the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section. Paper copies will be furnished upon request.

  10. The employee should be advised that it is their responsibility to provide medical evidence as to their duty status. It is also the employee's obligation to return to work as soon as possible. The manager should issue the CA-17, Duty Status Report, to the employee for each doctor's visit. The Form CA-16, should also be issued prior to the initial doctor's appointment if the appointment is within 7 days of the date of injury. The employee must return the Duty Status Report completed by the physician and/or other medical evidence to their manager. The Duty Status Report should be returned immediately after the examination or at the start of the employee's next scheduled work shift. If the employee is totally disabled, the form must be mailed without delay to the manager. Upon receipt, the manager must forward the medical documentation to the WCC.

  11. The manager must inform the employee that they are obligated to advise the physician that modified duty is available. The manager must monitor the employee's medical progress and duty status by obtaining periodic duty status until the employee is released to full duty. See Exhibit 6.800.1-1. Sample Letter to Physician Requesting Work Restrictions.

  12. If applicable, managers must track continuation of pay during to the 45-day entitlement period. See IRM 6.800.1.9. Continuation of Pay. Managers should consult with the WCC for assistance in tracking COP.

  13. Managers must carefully review the dates of disability on the Duty Status Report. If the employee can return to work, the manager must furnish the employee with a written description of the specific duties, physical requirements, and date of availability of the modified duty assignment. Exhibit 6.800.1-2, Sample Job Offer Letter. Have the employee sign and date the Acceptance/Declination Statement indicating their acceptance or declination of the modified duty offer. A copy of the signed statement must be furnished to the WCC.

  14. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.8  (02-25-2011)
Occupational Disease/Illness Claim Procedures (Includes Paper Claim Form CA-2 Methods)

  1. An occupational disease/illness is defined as a condition produced in the work environment over a period longer than ONE WORKDAY or SHIFT. It is this criterion that differentiates an occupational disease from a traumatic injury. Whereas a traumatic injury occurs within one workday, an occupational disease is caused by exposure over a period of more than one workday.

  2. The procedures for submitting occupational disease/illness claims (CA-2) are the same as those for traumatic injuries claims (CA-1). See IRM 6.800.1.7. Traumatic Injury Claim Procedures (Form CA-1), paragraphs 2 - 7.

  3. It is recommended that the employee and manager provide the information requested on the specified Form CA-35, Evidence Required in Support of a Claim for Occupational Disease. Form CA-35 checklists have been devised for various conditions to facilitate submission of supporting evidence. The CA-35 forms are available on the Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section. The employee completes their portion of the checklist and submits it to the manager, who completes the "Employing Agency" portion of the checklist. All information should be sent to the WCC. Do not delay submission of the CA-2 while gathering supporting documentation.

  4. Because CA-2 claims can be more complex cases, OWCP can take up to 6 months and occasionally longer to approve or deny an occupational disease/illness claim for benefits.

  5. The Employer will provide an employee who is injured while in work status with a copy of the Publication CA-550, FECA Questions and Answers about the Federal Employees' Compensation Act. Electronic copies of the CA-550 will be available through the Employee Resource Center (ERC) website at http://erc.web.irs.gov inWorkers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section. Paper copies will be furnished upon request.

  6. The employee should be advised that it is their responsibility to provide medical evidence as to their duty status. It is also the employee's obligation to return to work as soon as possible. The manager should issue the CA-17, Duty Status Report to the employee for each doctor's visit. The employee must return the Duty Status Report, completed by the physician, and/or other medical evidence to their manager. The Duty Status Report should be returned immediately after the examination or at the start of the employee's next scheduled work shift. If the employee is totally disabled, the form must be mailed without delay to the manager. Upon receipt, the manager must forward the medical documentation to the WCC.

  7. The manager must inform the employee that he/she is obligated to advise the physician that modified duty is available. The manager must monitor the employee's medical progress and duty status by obtaining periodic duty status until the employee is released to full duty. See Exhibit 6.800.1-1, Sample Letter to Physician Requesting Work Restrictions.

  8. Managers must carefully review the dates of disability on the Duty Status Report. If the employee can return to work, the manager must furnish the employee with a written description of the specific duties, physical requirements and date of availability of the modified duty assignment. See Exhibit 6.800.1-2, Sample Job Offer Letter. Have the employee sign and date the Acceptance/Declination Statement indicating their acceptance or declination of the modified duty offer. A copy of the signed statement must be furnished to the WCC.

  9. Form CA-16 is not issued for occupational disease claims. Refer to 6.800.1.6(g) for guidance on obtaining medical documentation to support the employee's duty status.

  10. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.9  (02-25-2011)
Continuation of Pay (COP)

  1. Continuation of Pay (COP), FECA leave, is the continuation of an employee’s regular pay by the employing agency when absence is directly related to the injury. If the injury causes the employee to miss time from work, the manager must advise the employee of the right to elect COP or to use annual and/or sick leave. The employee may not use leave to extend the 45-day entitlement period.

  2. COP is applicable in traumatic injury cases only and available only for a maximum of 45 calendar days. COP days includes each work day the employee is absent for any part of the day, and non-work days including holidays, weekends, and alternate work schedule (AWS) days off. The days do not have to be used consecutively, but must be used within 45 calendar days from:

    • the date of injury, or

    • the date the employee first returns to work following the initial disability, whichever is later.

  3. To qualify for COP, an employee must file a traumatic injury claim (CA-1) within 30 days of the date of injury. The employee should indicate their COP election when filing the injury claim. Medical evidence supporting disability must be submitted by the employee within 10 calendar days. The 10-day period begins with the workday after the employee claims COP or the date disability begins, whichever is later. Management must first notify the WCC before authorizing COP. In some instances, if the claim is controverted or challenged. COP may be denied or suspended. Refer to Publication CA-550, FECA Questions and Answers for specific reasons that employing agencies may deny COP. Consult the WCC for guidance. See also IRM 6.800.1.12, Controversion of COP/Challenge of Claim.

  4. On the day of the accident, an injured employee's absence from work to seek medical attention and for documented disability on that date is usually charged to administrative leave. COP usually starts the first day of absence following the date of injury. If the injury occurs before the start of the employee's tour of duty, COP is charged for any disability on the date of injury. COP is counted in one-day increments, even if the employee worked a portion of the day.

  5. A Workers’ Compensation Case Manager at the WCC will assist managers in closely monitoring the duration of COP. Dates of eligibility for COP should be compared with medical reports regarding an employee’s inability to work. In cases where the employee has elected sick or annual leave, the employee will be placed in a leave status. However, medical documentation is required for all absences, due to work-related injury/illness, regardless of the type of leave requested.

  6. COP is not authorized for occupational illnesses (Forms CA-2).

  7. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.10  (02-25-2011)
Claim for Wage Loss Compensation (Form CA-7)

  1. If an employee sustained a traumatic injury and the employee cannot return to work at the end of a 45-day period of COP, the employee may choose to be placed in OWCP-LWOP leave status and file a claim requesting wage loss compensation from OWCP. The employee may also opt to use personal leave and file for a Leave Buy Back at a later time. See IRM 6.800.1.11. The following procedures apply to employees using OWCP-LWOP and filing for wage loss compensation:

    1. At the end of the 45-day period of COP (applicable for Form CA-1) or upon acceptance of Form CA-2, the employee should complete the front of the Form CA-7 and submit the form and supporting medical documentation to their manager. For intermittent absences, Form CA-7a, Time Analysis, is required. Both forms are available on the Employee Resource Center (ERC) website at http://erc.web.irs.gov in the Workers' Compensation section in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section

    2. The manager should complete the back of the CA-7 form and then forward the completed form with all relevant medical evidence to the WCC. The CA-7 form is used by OWCP to determine the compensation entitlement. Therefore, accuracy in completing the information pertaining to the employee's pay rate, health and life insurance, and retirement plan is critical. OWCP pays at the rate of 75% of the claimant’s salary, for those injured employees with children under 19 (or under qualified schooling) and/or a spouse. Those employees with no qualifying dependents are paid at 66 2/3% of their salaries. Compensation paid by OWCP is not subject to income tax.

    3. If the disability is expected to continue beyond the period claimed on the initial CA-7, the employee should complete subsequent Forms CA-7 every two weeks until he/she returns to work on limited/regular duty, or until otherwise directed by the WCC or the servicing OWCP office. If the employee accumulates 80 hours or more of OWCP-LWOP leave, the manager must prepare a Personnel Action Request (PAR) to document the employees compensable leave status. PAR actions must be processed to document any additional 80-hour periods of OWCP-LWOP.

    4. Contact the employee’s Workers' Compensation Case Manager by telephone immediately after the claimant returns to work. Telephone notification is critical to prevent a possible overpayment by OWCP.

    5. If the employee returns to work with restrictions, prepare a written job offer using the Job Offer Letter found in Exhibit 6.800.1-2, Sample Job Offer Letter.

    6. Contact the WCC toll-free at 800-234-8323 for assistance in filing for wage loss compensation and issuing Job Offer Letters.

6.800.1.11  (08-25-2009)
Leave Buy Back (LBB)

  1. A leave buy back or leave restoration is a process by which sick or annual leave used during a period for which OWCP compensation benefits are payable is re-purchased by the employee. The leave is then restored to the employee's personal leave account. Credit and/or compensatory hours may not be repurchased under the Leave Buy Back Program. The leave buy back process may take up to eighteen months to complete.

  2. Requirements - IRS Workers' Compensation Leave Buy Back Program

    1. Applicants for leave buy back must be current (on the rolls) IRS employees;

    2. Applicants must have an OWCP-approved workers' compensation claim including OWCP-approved recurrence claims where applicable;

    3. Applicants must apply for leave buy back within one year of the date OWCP approved the original claim (for clarification see subsections (4) and (5) below);

    4. Applicants must apply for leave buy within one year from the date OWCP approved a recurrence claim (for clarification see subsections (4) and (5) below);

    5. Applicants must apply for leave buy back prior to accepting third party settlements;

    6. Applicants must repurchase a minimum of 10 hours of leave;

    7. Applicants must submit Form CA-7 (Claim for Compensation) and Form CA-7a (Time Analysis) with supporting medical documentation through their manager to the WCC;

    8. In order for leave to be reinstated, applicants must pay IRS in full for the difference between the total cost of the leave buy back (100% of salary) and the OWCP contribution (66 2/3% or 75% compensation rate paid by OWCP; and,

    9. Applicants must submit leave buy back requests directly to WCC, not OWCP, since WCC approval of the request is required.

  3. Other Requirements:

    1. Checks for compensation from OWCP in connection with a leave buy back must be sent directly to the WCC;

    2. Managers must adhere to guidance provided by the IRS WCC, since general guidelines for leave buy back issued by OWCP are not agency specific;

    3. If claimed and approved as part of a Leave Buy Back, leave received from the Leave Bank or from leave transfers must be repaid to the Leave Bank or the leave donor;

    4. Leave that is repurchased is re-credited to the year in which the leave was actually used. If the employee buys back annual leave that results in an end-of-leave-year balance in excess of the maximum permissible carryover balance (typically 240 hours), the excess leave will be forfeited and may not be restored;

    5. Some loss of leave accrual may occur when the period of absence is changed to leave without pay (LWOP) status as a result of leave buy back. For every increment of 80 hours of leave repurchased and changed to LWOP, both annual and sick leave accruals will be reduced by the amount of leave normally earned in that pay period;

    6. The National Finance Center (NFC) maintains IRS payroll accounts; therefore, applicable NFC regulations must be followed;

    7. The designated IRS Payroll Center will conduct all audits for Leave Buy Back based on information provided by WCC. The Payroll Center will use current payroll guidelines to restore all leave to the claimant's leave account in all payroll systems; and

    8. Employees who filed workers' compensation claims prior to 8/25/2009, may apply and will receive consideration for Leave Buy Back under the previous Leave Buy Back policy dated 01/01/2004.

  4. Filing Deadlines for Leave Buy Back (LBB) Applications

    IF AND YOU MUST FILE LBB APPLICATION TO WCC NO LATER THAN (NLT)
    Original Claim accepted by OWCP on 12/01/2009 No Recurrence Claim filed 1 year from Date Original Claim Accepted (i.e.), 11/30/2010
    Original Claim accepted by OWCP on 12/01/2009 Recurrence Claim Filed & Accepted on 9/15/2010 11/30/2010 - For Leave Attributable to Original Claim and
    9/14/2011- For Leave Attributable to Recurrence Claim
    Note: If no LBB was filed for the Original Claim (or was timely filed), only leave attributable to the Recurrence Claim is available for LBB provided Recurrence LBB is timely filed
    Original Claim accepted by OWCP on 12/01/2009 Recurrence Claim Filed & Denied by OWCP 1 year from Date Original Claim Accepted (i.e., 11/30/2010) For Leave Attributable to Original Claim; For Leave Attributable to Recurrence Claim, LBB option is not available since Recurrence was denied.
  5. Clarifying Scenarios for Acceptance of LBB Requests:

    SCENARIO NUMBER IF THEN REASON
    (1) An employee's workers' compensation claim is approved by OWCP on 12/01/2009. The employee submits Forms CA-7, CA-7a, and supporting medical documentation to WCC on 01/01/2011. The leave buy back application is denied as untimely. The employee must apply for Leave Buy Back within one year of the date OWCP approved the claim. The last date eligible in this case would have been 11/30/2010.
    (2) An employee makes application to the WCC on 11/07/2010 to buy back leave by submitting Forms CA-7, CA-7a, and supporting medical documentation for a recurrence claim which was accepted by OWCP on 12/02/2009. The leave buy back application will be accepted for processing. The employee filed a recurrence claim (Form CA-2a) and had received a formal approval from OWCP. In addition, the employee met the time requirements to apply for the leave buy back within one year of the date OWCP approved the recurrence claim (i.e., no later than 12/01/2010).
    (3) On 10/20/2009, OWCP accepted an employee's claim for injury that occurred on 09/03/2009. The employee did not apply for a leave buy back. The employee subsequently filed a claim for recurrence of injury on 10/03/2010, which was formally adjudicated and accepted by OWCP on 12/01/2010. The employee applied for a leave buy back for the period 09/03/2009 through 12/01/2010. The request for leave buy back was received by the WCC on 03/08/2011. The leave buy back application for leave attributable to the original claim is denied. The employee did not meet the time limitation to buy back leave used for the original claim. The employee must file for leave buy back within one year of the date OWCP accepted the original claim. In this case, the last date eligible to buy back leave for the original claim would have been 10/19/2010. The request was not received until 03/08/2011.
    The employee would be eligible to submit a request for leave buy back for the leave attributable to the recurrence claim. The employee could submit a request to buy back any leave used from 10/03/2010 (the date the recurrence began) through 11/30/2011 (one year from the date OWCP approved the recurrence claim).
    (4) An employee's workers' compensation claim for injury on 10/25/2009 was approved by OWCP on 04/20/2010. The employee filed for a leave buy back for time used for the injury on 05/10/2010. A leave buy back is approved, processed, and leave is restored to the employee's account after the employee pays the difference between the leave pay received and the amount of compensation payable by OWCP.
    The employee again stops work on 06/12/2010 due to the effects of the original injury. The employee files for a leave buy back on 12/12/2010 for the leave used between 06/12/2010 and 10/11/2010
    The leave buy back application for the work stoppage that began 06/12/2010 is denied. The employee did not file a recurrence claim (Form CA-2a) for the work stoppage that began on 06/12/2010; therefore, a leave buy back request for the recurrence will not be approved.
    Although the employee applied for a leave buy back within the time limits for the originalclaim, a leave buy back was previously processed for that claim. In order to buy back the leave for time used beginning 06/12/2010, the employee must have an approved recurrence claim.

6.800.1.12  (02-25-2011)
Controversion of COP / Challenge of Claim

  1. "Controvert" means to dispute COP entitlement. In certain circumstances, COP may be denied or suspended by the employing agency (IRS). Reasons for withholding the payment of COP include:

    1. The injury was not reported on Form CA-1 within 30 days following the date of injury.

    2. COP is claimed for an occupational disease or illness.

    3. The injury occurred off the employing agency's premises and the employee was not involved in official "off premises" duties.

    4. Work stoppage first occurred 45 days or more following the injury.

    5. The employee initially reported the injury after his or her employment was terminated.

    6. The injury was proximately caused by the employee's willful misconduct, intent to bring about injury or death to self or another person, or intoxication.

  2. Refer to OWCP's Publication CA-550, FECA Questions and Answers, for the specific reasons employing agencies may withhold the payment of COP. Consult the WCC Case Management Specialist for guidance when entitlement to COP is questioned.

  3. For the purposes of this section, "Challenge" means to question the validity of a statement, record, action or reported fact concerning the claimed injury or entitlement to coverage under the FECA.

  4. If the preliminary review of the CA-1, CA-2, CA2a, witness statement, or medical report suggests that the claim is unjustified, the agency may challenge the entire claim or any portion of it. It is the responsibility of all managers to dispute any claim or any element of a claim, for which there is credible evidence of:

    1. Fraud and/or abuse,

    2. Honest misjudgment by the employee, or

    3. Any other circumstances which constitute doubt as to the employee's entitlement to workers' compensation benefits.

  5. It is essential that the agency provide all pertinent facts as soon as the information is available. FECA regulations provide that, absent a full reply from the agency, OWCP will accept the claimant's statements/allegations as factual and will assume that the agency fully concurs with them. The agency has no appeal rights in the claim's adjudication process; therefore, it is critical that all factual evidence be provided without delay to the WCC for submission to the OWCP.

6.800.1.13  (02-25-2011)
Appeal Rights

  1. The OWCP makes formal decisions on whether injured employees are entitled to benefits and compensation under the FECA. OWCP will provide reasons for denial of benefits and include a description of employee's appeal rights.

  2. If the employee disagrees with the OWCP’s formal decision, he/she has the following appeal rights:

    1. oral hearing or review of the written record by OWCP,

    2. reconsideration, or

    3. review by the Employees' Compensation Appeals Board (ECAB).

  3. Employees may request only one form of appeal at a time and each appeal has time limits as prescribed by OWCP.

  4. Employees or managers wishing information regarding the appeal process may contact WCC for more information.

6.800.1.14  (02-25-2011)
Manager's Initial Claims Management

  1. The management of the claim is the responsibility of IRS management and the WCC. All claims and related correspondence (except medical bills) must be submitted to the WCC for forwarding to OWCP. This includes claims filed with no lost time and no medical expense.

  2. Upon receipt of an injury claim, the manager will establish a case file folder to be maintained in his/her office. If the employee changes managers, this file should be provided to the employee's new manager. The manager's case file may be destroyed three years after the employee has returned to full duty without restriction and no further medical care is required. The WCC will establish and maintain the official agency case file.

  3. Upon notification that an injury/illness has occurred, the employee's manager should determine the facts and circumstances of the injury/illness. The facts should either substantiate the claim or raise doubt as to the validity of the claim. Some sources and expertise available for gathering information are:

    • Injured employee

    • Witnesses

    • Immediate manager and section chief

    • Medical documentation

    • Safety Officer

    • Local law enforcement agencies

    • On-site occupational health nurse

  4. Based on the information gathered, the manager/WCC will determine whether to contest the claim. If there is no basis for challenging the claim, the claim and all supporting documentation will be immediately forwarded to the WCC. If the information reveals that there are questionable circumstances, the manager will notify the WCC and prepare a written statement outlining the facts. Do not delay the submission of the claim pending preparation of the statement. This topic is also discussed in the following subsection. IRM 6.800.1.12., Controversion of COP / Challenge of Claim.

  5. The submission of the injury/illness claim should not be unduly delayed. If medical reports and supporting information are not readily available, do not delay submission of the claim. This is in order for a claim number to be assigned and the processing of the claim to be initiated. The regulations in 20 CFR 10.16 provide penalties for willfully interfering with the filing of an injury/illness claim.

  6. Additional information and forms are available on the IRS Employee Resource Center (ERC) website at http://erc.web.irs.gov in Workers' Compensation articles at http://erc.web.irs.gov/Displayanswers/Question.asp?FolderID=5&Category ID=84 under the Pay, Leave, and Benefits section.

6.800.1.15  (02-25-2011)
Extended Periods of Disability

  1. When it is apparent the injured employee will be disabled from work for an extended period of time, OWCP may take action to facilitate the injured worker's recovery and return to work. As the official IRS liaison to OWCP, the WCC has the authority to contact OWCP to discuss the next steps for case management.

  2. OWCP provides information to the employee generally in writing (copy to the WCC), concerning actions taken or proposed regarding the case. The following are some case management activities OWCP may pursue:

    1. Schedule conference calls with employees and/or managers/WCC case workers to discuss claim progress.

    2. Request detailed medical information from treating physicians.

    3. Assign OWCP contract nurses to facilitate medical treatment and return to work efforts.

    4. Assign contract rehabilitation counselors may also provide vocational testing services and determine the need for further training of the injured worker to facilitate job placement.

    5. Initiate detailed medical examinations by scheduling second opinion and/or referee medical examinations.

6.800.1.16  (02-25-2011)
Return to Work

  1. The Federal Employees' Compensation Act (FECA) provides Workers' Compensation benefits to Federal employees who sustain job-related injuries or illnesses. Title 5 USC 8151 and Federal Regulations 5 CFR part 353 also provides injured workers with certain rights once they fully or partially recover from the compensable injury or illness. The regulations at 20 CFR part 10 also require injured workers who have fully or partially recovered to seek and accept suitable work when no longer totally disabled.

  2. Restoration rights are governed by 5 USC 8151. The Office of Personnel Management (OPM) issues and administers the restoration rights provisions of the law found at 5 CFR part 353, subparts A and C. Restoration rights are not under the jurisdiction of the OWCP. Restoration of individuals who sustain compensable injuries or illnesses will be in accordance with 5 CFR part 353 subparts A and C.

    1. Fully Recovered Within One Year – A current or former employee who fully recovers from a compensable injury within one year from the date eligibility for compensation began, is entitled to be restored immediately and unconditionally to their former position or an equivalent one. Although these restoration rights are agencywide, the employee's basic entitlement is to their former position or equivalent in their local commuting area. An employee who fully recovers within one year will receive employment consideration in accordance with 5 CFR 353.301 (a). Managers should consult their Servicing Employment Offices for guidance concerning restoration rights and placement assistance if needed.

    2. Fully Recovered After One Year - An employee who separated because of a compensable work injury and whose recovery takes longer than one year from the date eligibility for compensation began, is entitled to priority consideration. Priority consideration is Treasury-wide for restoration to their former position or equivalent provided they apply for reappointment within thirty calendar days of the cessation of compensation. Priority consideration is accorded by adding the employee to the Agency's reemployment priority list. A current or former employee who fully recovers from a compensable injury after one year will receive employment consideration in accordance with 5 CFR 353.301(b). Managers and injured workers should contact their Servicing Employment Office for guidance concerning reemployment priority consideration.

    3. Partially Recovered - In instances where injured workers have partially recovered from a compensable work-related injury or disability and are able to return to limited/modified duty, every effort will be made to restore them to an appropriate position. According to OPM, this means that IRS is expected to make a good faith effort to find an appropriate position. Based on the OPM guidelines, this requires IRS, at a minimum, to treat these individuals substantially the same as other disabled individuals are treated under the Rehabilitation Act of 1973, as amended. Partially recovered individuals will receive employment consideration in accordance with 5 CFR 353.301(c) and (d). Servicing Employment Offices can provide guidance concerning restoration entitlements. The WCC will provide guidance and assistance to facilitate the return-to-work effort to ensure FECA requirements are met.

  3. An effective return-to-work process for injured workers requires the collaboration and cooperation of IRS Leadership at all levels. This includes the Operating Divisions, WCC, the various support functions and the injured worker. The value proposition for this collaboration is the timely and safe return to work for an injured employee. Not only is productivity enhanced, but we have reduced the human and economic impact of workplace injuries and illnesses. When suitable work is not available, evidence of the agency's placement efforts is needed to document that the agency has "made every effort" to accommodate the injured worker.
    This subsection defines steps that must be taken to search for suitable work, including a search across functional/organizational lines to meet agency obligations under existing laws and regulations identified above. Because the regulations concerning return to work entitlements for injured workers who fully recover from compensable work-related injuries/illnesses are well defined under 5 CFR 353.301(a) and (b), those entitlements are not addressed in this subsection.

  4. The WCC will work with Servicing Employment Offices to ensure that individuals who are fully or partially recovered from compensable work-related injuries and illnesses are returned to work in accordance with applicable laws and regulations. These procedures supplement IRM 6.335.1, Promotion and Internal Placement, Merit Promotion Plan and Internal Placement concerning employees with statutory placement rights.

  5. The IRS will make every effort to identify suitable positions for current and former employees who have partially recovered from compensable work-related injuries and illnesses. A search for suitable placement opportunities must be conducted within the injured worker's local commuting area. The definition of "local commuting area" is set forth in 5 CFR 351.203 and is further described in IRM 6.335.1, Promotion and Internal Placement. If after considering available placement options within the commuting area, suitable work cannot be identified, the first-level executive of the injured employee will certify that suitable work is not available. This certification will include documentation to support such findings.

  6. In accordance with Treasury's Workers' Compensation Program Policy, IRS Leadership will work with the Workers' Compensation Program staff, other Human Resources personnel, and EEO Reasonable Accommodations staff to identify light, limited, or modified duty assignments for injured workers able to return to restricted work. The goal is to return injured workers to gainful employment as soon as medically feasible. The support and assistance of Human Resources functions and the Equal Employment Opportunity and Diversity staff will be provided to facilitate return-to-work efforts.

  7. Return to Work Procedures:

    1. When an injured worker has partially recovered from a compensable injury or disability, the IRS will make every effort to assign the injured worker to duty (or re-employment) consistent with their medically defined work limitation tolerances. In assigning such duty, the IRS should minimize the adverse or disruptive impact on the injured worker.

    2. It is the ultimate goal that the injured worker be place in a position that will provide the same employment status and pay or the nearest approximation thereof if an equivalent position is not available.

    3. At a minimum, the following steps must be taken in identifying suitable work when an injured worker is able to return to work in a limited capacity.

    Identifying Suitable Work
    Step Action Required
    1.
    1. The WCC will notify the manager of the partially-recovered injured worker that work restrictions have been identified and request that a search be conducted to identify suitable work consistent with the injured worker's medically defined work limitations.

    2. If the injured worker is a former employee, the WCC will send notification to the designated business operating division or principal IRS office (BOD/PO) contact point to coordinate return-to-work placement activities.

    3. Should this effort fail, the injured worker may be offered other lower-graded/salaried positions for which the employee is qualified after a search is conducted for equivalent position(s) elsewhere in the commuting area. See Step 5.

    2.
    1. If suitable work is available, the injured worker's manager and the WCC will work together to compose a formal written offer of work within the specified work restrictions for issuance to the injured worker.

    2. The manager will issue the written job offer to the injured worker requesting his/her acceptance or declination of the offer.

    3. WCC must be furnished a copy of the written job offer and the injured worker's acceptance or declination.

    4. If the injured worker declines a job offer, the manager must contact the WCC.

    3.
    1. If the manager is unable to accommodate the medical restrictions within the work unit, the manager will elevate WCC's request for identification of a position to the first-level executive of the BOD/PO to conduct a search within the commuting area for a suitable position elsewhere within the BOD/PO.

    2. The BOD/PO will continue to search for a suitable position until the employee is appropriately placed in another position or WCC notifies the BOD/PO to cease search efforts.

    4.
    1. If the BOD/PO is not able to find suitable work within the BOD/PO, the first-level executive will provide WCC a signed statement outlining the attempts to identify suitable work and the reasons for the inability to accommodate the partially-recovered injured worker. See Exhibit 6.800.1-3, Business Operating Division/Principal Office (BOD/PO) Executive's Certification of Inability to Identify Suitable Employment for Partially Recovered Injured worker.

    5.
    1. Since there may be multiple Servicing Employment Offices for a particular geographic location or commuting area, Employment will designate a central point of contact to work with WCC to coordinate the employment search.

    2. the WCC will contact Employment's designated central point of contact requesting assistance in determining the injured worker's qualifications for other positions and the availability of those positions within the commuting area.

    3. If Employment cannot identify positions within the commuting area for which the injured worker qualifies, Employment will provide initial certification to WCC that no positions are available at the present time, and that Employment has not received notification of any anticipated vacancies in the near future.

    4. If Employment does identify positions within the commuting area, Employment will notify WCC of the positions.

    5. If there are current vacancies for any of the positions for which the injured worker qualifies, Employment will advise WCC of those vacancies and the applicable BODs/POs where such vacancies exist.

    6. Employment will continue providing employment search assistance to WCC as requested or until WCC advises otherwise. See Exhibit 6.800.1-4, Employment Office Certification Injured Worker Position Qualifications and Vacancies.

    7. WCC will contact the identified alternate BOD/PO(s) for placement assistance.

    8. The alternate BOD(s)/PO(s) will follow Step Two or Step Four as applicable.

    9. If suitable work cannot be identified by the alternate BOD/PO, the first-level executive will complete. See Exhibit 6.800.1-5 (Alternate) Business Operating Division/Principal Office (BOD/PO) Executive's Certification of Inability to Identify Suitable Employment for Partially Recovered Injured Worker.

    6.
    1. Documentation concerning the agency's attempts to identify suitable work and the reasons for the inability to accommodate the injured worker will be placed in the individual's workers' compensation file to demonstrate that IRS has made every reasonable effort to identify suitable work as required by law. See Exhibits 6.800.1-3, -4, -5, as applicable.

    2. Upon receipt of documentation that the agency is unable to place the injured worker, the WCC will notify the Office of Workers' Compensation Programs (OWCP) and request that vocational rehabilitation services be provided to assess and/or prepare the injured worker for placement with another employer.

Exhibit 6.800.1-1 
Sample Letter to Physician Requesting Work Restrictions

Sample Letter to Physician Requesting Work Restrictions
Physician’s Name
Physician’s Address
   
    Claimant:
Claim #:
SS#:
DOI:
Dear Dr. __________:
This is regarding the workers’ compensation claim filed by our employee and your patient, (Employee Name). The IRS is committed to accommodating any work restrictions you deem medically necessary. Light duty assignments are available based on the work restrictions you provide. Most positions at the IRS are sedentary in nature.
 
For this reason, we would appreciate your completing the enclosed Form CA-17, Duty Status Report outlining current work restrictions. To assist you in making your determination, we have enclosed a copy of the position description. Your response may be faxed to (employee’s manager) at (fax number).
We appreciate your cooperation in this matter and look forward to working with you. If you have any questions regarding the employee’s work requirements, please contact (employee’s manager) at (telephone #). Questions pertaining to Internal Revenue Service workers’ compensation issues may be directed to our Workers’ Compensation Center located in Richmond, Virginia, at 1-800-234-8323.
  Sincerely,




Manager
Manager’s Title
 
Enclosures (CA-17 Duty Status Report is available at : http://www.dol.gov/owcp/regs/compliance/ca-17.pdf)

cc: Workers’ Compensation Center

Exhibit 6.800.1-2 
Sample Job Offer Letter

Sample Job Offer Letter (put on your agency's letterhead)
Employee’s Name
Employee’s Address
Dear    
We have received medical information from your physician indicating you can return to work/increase your hours to __________hours per day as of __________. In accordance with your medical restrictions provided, the following position is offered to you:
Title:

Series/Grade/Salary:
Organization/Location:
Tour of Duty/Hours of Work:
Date Job Available: (use date of job offer letter)
The following describes the duties and physical/environmental requirements of this position.

Caution:

The functional requirements of the offered position must be included in narrative format and must comply with the individual’s physical limitations.

Example:

While sitting in a chair, you input data into a remote computer terminal. The terminal is at eye level when the operator is in a sitting position and no reaching or working above shoulder level is required. You may occasionally be required to move and carry computer listings short distances. The weight of the listings does not exceed 10 pounds. You may be required to walk short distances on an intermittent basis, not to exceed at total of 1 hour per day. No stair climbing is involved. You will be working indoors and will not be exposed to cold or dampness. You will be allowed to sit or stand at your convenience, for comfort, and you will be permitted to take frequent walks.] A copy of the official position description is attached.

If you decline this position and OWCP determines that this is a job that you can perform, your benefits under the Federal Employees’ Compensation Act may be terminated (except for medical benefits). If you accept this position, we will provide the necessary information to the OWCP claims examiner for determination of loss of wage earning capacity, if any. You will receive applicable credit for the time spent on the OWCP compensation rolls for leave and retirement purposes, in accordance with law and regulation. Your decision as to acceptance or declination of this offer should be made in writing within 5 days of the date of this letter. The enclosed Acceptance/Declination Statement is provided for this purpose. Failure to notify this office of your decision will constitute a rejection of a valid re-employment offer and may serve as a legal basis for OWCP to terminate benefits.
If you have any questions, contact me at __________at (telephone #).
  Sincerely,




Manager
Manager’s Title
 


Enclosure
cc: WCC Claims Specialist
ACCEPTANCE/DECLINATION STATEMENT
( ) I, __________, voluntarily ACCEPT the position of__________ ( Title, Series/Grade/Step), at an annual salary of $_____. I make this acceptance voluntarily without pressure or coercion. I understand that if OWCP benefits are currently being received, this voluntary acceptance of the position being offered may result in a reduction or termination of such benefits.
__________
Signature
_____
Date
( ) I, __________, DECLINE this offer of placement in the position of _____(Title, Series/Grade/Step), at an annual salary of $_____. I fully understand the consequences that if I decline the job offer and OWCP determines that this is a job I can perform, my compensation benefits may be terminated under 5 USC Section 8106 (c).
Give reason for declination:
__________
Signature
_____
Date
FAILURE TO RESPOND TO THIS JOB OFFER WILL BE CONSIDERED A DECLINATION
cc: WCC Claims Specialist

Exhibit 6.800.1-3 
Business Operating Division/Principal Office (BOD/PO) Executive's Certification

Business Operating Division/Principal Office (BOD/PO Executive's Certification Of Inability To Identify Suitable Employment For Partially Recovered Injured Worker
I certify that efforts to accommodate, __________'s work restrictions due to a compensable on-the-job injury on__________(date) have been unsuccessful. The following actions have been taken:
__________Attempted to modify present (or former) position;
__________Attempted to assign to an equivalent position (with or without modification) within the injured worker's BOD/PO; and
__________Attempted to assign a lower-graded position (with or without modification) within the commuting area.

Note:

A search for an equivalent position outside the BOD/PO must be conducted by the WCC and the Servicing Employment Office prior to offering a lower-graded position. However, the availability of a lower-graded position within the BOD/PO and commuting area should be identified for possible placement if an alternative equivalent position cannot be located. Contact the WCC for assistance.)

Reasons for inability to provide suitable work for __________
(Name of Injured Worker)
__________
Printed Name (First-Level Executive or Above)
_____
Title
__________
Signature (First-Level Executive or Above)
_____
Date
Return completed form to:
Workers' Compensation Center
400 N. 8th Street, Box 78
Richmond, VA 23219-4838

Exhibit 6.800.1-4 
Employment Office Certification Injured Worker Position Qualifications and Vacancies

Employment Office Certification Injured Worker Position Qualifications and Vacancies
Section 1: Position for which __________(the injured worker) qualifies:
If there are no positions to list here, complete Section 2
Position Title Series Grade Business Operation Division/ Principal Office Geographic Location Current or Anticipated Vacancy Yes/No
           
           
           
           
           
Section 2:
I certify that I have reviewed all available information and have determined that except for the injured worker's position of record, there are no positions in the commuting area for which __________(name of injured worker) qualifies.
__________
Printed Name (Employment Official)
_____
Title
__________
Signature (Employment Official)
_____
Date
Return completed form to:
Workers' Compensation Center
400 N. 8th Street, Box 78
Richmond, VA 23219-4838

Exhibit 6.800.1-5 
Alternate Business Operating Division/Principal Office (BOD/PO) Executive's Certification

Alternate Business Operating Division/Principal Office (BOD/PO) Executive's Certification Of Inability To Identify Suitable Employment For Partially Recovered Injured Worker
I certify that efforts to accommodate, __________'s work restrictions due to a compensable on-the-job injury on__________(date) have been unsuccessful. The following actions have been taken:
__________Attempted to assign injured worker to an equivalent position (with or without modification) within his/her commuting area; and
__________Attempted to assign injured worker to lower-graded position (with or without modification) within his/her commuting area
Reasons for inability to provide suitable work for __________
(Name of Injured Worker)
__________
Printed Name (First-Level Executive or Above)
_____
Title
__________
Signature (First-Level Executive or Above)
_____
Date
Return completed form to:
Workers' Compensation Center
400 N. 8th Street, Box 78
Richmond, VA 23219-4838

Exhibit 6.800.1-6 
Return to Work Flowchart

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