CA-1: Traumatic Injury Claim Form

All injuries must be reported to Occupational Medical Service (OMS) immediately. If your employee has not done so, refer them to OMS before completing the CA-1 form.

You should receive a page of instructions from your employee.  Please refer to the supervisor portion for assistance.

The CA-1 form is used if the employee has sustained a Traumatic Injury on the job.

Traumatic Injury - A wound or other condition of the body caused by external force, including stress or strain. Must be identifiable by time and place of occurrence and member of the body and must be caused by a specific event of series of events or incidents within a single day or work shift.

For further guidance on using ECOMP:

Completing the form

As the supervisor, it is your responsibility to complete this form.  However, if you have any reason to believe that the information provided by the employee is not correct, there are sections of the CA-1 where additional information should be provided:

Section 28: Was the employee injured in the performance of duty?

Performance of Duty - Coverage includes injuries that occur while on agency premises during working hours, while on the premises for a reasonable length of time before or after working hours, in agency parking facilities, on official travel, or engaged in formal or agency-sanctioned recreation. Other circumstances may be considered.

If you select “no”, please provide information regarding the employee’s injury that would lead you to believe he/she was not in the performance of duty when the injury occurred. 

Section 29: Was injury caused by employee's willful misconduct, intoxication, or intent to injure self or another?

If you select “yes” provide a statement and include any additional documentation pertaining to this statement.

NOTE: additional documentation can be uploaded directly to this form using ECOMP

Section 35: Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses?

If you select “no” you may provide a statement and include any additional documentation pertaining to this statement.

Procedures after completing the CA-1

Once the forms are completed in ECOMP, they must be submitted to you (please note- a wet signature is required). The original copy of the completed, signed CA-1 form must be sent to the NIH Workers’ Compensation Program. In addition, you should discuss Continuation of Pay (COP) and other facts that may be pertinent to the injured employee such as the estimate return to work date.

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