A federal employee's supervisor uses this report to get the doctor's current work restrictions after an on-the-job injury. Side A describes the injury and the job's physical demands; Side B records the physician's findings, diagnosis and whether the employee can resume regular or modified work, with hours per day for each activity. The agency relies on it to offer suitable duty and to avoid interrupting the employee's income.
The supervisor completes Side A (items 1 to 7: employee details, how the injury occurred, work schedule and usual work requirements) and refers the form to the physician. The physician completes Side B (items 8 to 20), covering clinical findings, diagnoses, work capacity by activity, exam dates, specialty, tax ID and the signature in block 19.
The OWCP file number goes in the top right corner if it is known, and the supervisor enters it when completing Side A. The header states that the request does not authorize payment of medical expenses by the Department of Labor and does not invalidate any earlier authorization in the case, such as a CA-16.
The supervisor enters the employee's name, date of injury, Social Security number and occupation, describes how the injury occurred and the body parts affected, and gives the hours per day and days per week the employee works. Item 7 lists the usual work requirements, marking each task as continuous or intermittent with hours, which the physician compares with the employee's capacity.
Item 8 asks whether the history the employee gave you matches the supervisor's description in item 5; if not, describe the difference. Then describe the clinical findings (item 9), list the diagnoses due to the injury (item 10) and note any other disabling conditions (item 11), keeping injury-related diagnoses separate from unrelated ones.
Item 12 records whether you advised the employee to resume work and the date. Item 13 asks whether the employee can perform the regular work described on Side A; if yes, full time or part time and hours per day. If no, complete the activity grid with continuous or intermittent hours per day for lifting and carrying (with maximum weight), sitting, standing, walking, climbing, kneeling, bending, twisting, pulling and pushing, grasping, fine manipulation including keyboarding, reaching above shoulder, driving and operating machinery.
The same grid covers exposures: temperature extremes as a range in degrees F, high humidity, chemicals and solvents, fumes and dust (identify them), noise in dBA, and any other factor you describe. Give the tolerated hours per day for each so the agency can compare them with the exposures the supervisor listed for the job in item 7.
Answer whether interpersonal relations are affected because of a neuropsychiatric condition, for example the ability to give or take supervision or to meet deadlines, and describe the effect if you answer yes. This is the only place on the CA-17 for psychological limits, which otherwise would not show up in the physical activity grid.
Enter the date of examination, the date of the next appointment, your specialty and tax identification number, then sign block 19 and date block 20. Signing block 19 certifies that your answers are true, complete and correct and acknowledges that the form does not authorize payment by DOL. Fill in your name and address in the medical facility block on page 2.
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The instructions tell the physician to complete Side B, sign it and return it to the employing agency within 2 days to prevent interruption of the employee's income. The agency compares your restrictions with the job demands on Side A to decide whether it can offer regular or modified duty, so a late form can hold up the employee's return to work.
The CA-17 is a short duty status report that the supervisor starts and the physician finishes to set current work restrictions, and it goes back to the employing agency. The CA-20 Attending Physician's Report covers diagnoses, ICD codes, the causal relationship to employment and periods of disability for the compensation claim, and it goes to OWCP.
Item 8 asks whether the history the employee gave you matches the supervisor's description in item 5. Answer no and describe the differences, then complete the rest of Side B and sign block 19. Signing certifies that your statements are true, complete and correct, and knowingly false statements may lead to criminal prosecution.