This form contains 130 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Information
form1[0].#subform[0].#area[1].RadioButtonList[0]_0	ComboBox	Select this radio button if it applies to your situation.
form1[0].#subform[0].#area[1].RadioButtonList[0]_1	ComboBox	Select this radio button if it applies to your situation.
This field is a check box. Select this box if it applies to you	CheckBox	Select this checkbox if it applies to you.
This field is a check box. Select this box if it applies to you	CheckBox	Select this checkbox if it applies to you.
form1[0].#subform[1].#area[11].RadioButtonList[9]_0	ComboBox	Select this radio button if the condition applies. The specific condition is not provided in the field name.
form1[0].#subform[1].#area[11].RadioButtonList[9]_1	ComboBox	Select this radio button if the condition applies. The specific condition is not provided in the field name.
Agency Information
17. Agency name and address of reporting office (include street address, city, state, and ZIP code)	Text	Enter the name and full address of the reporting office, including street address, city, state, and ZIP code.
OWCP Agency Code	Text	Provide the OWCP (Office of Workers' Compensation Programs) Agency Code.
OSHA Site Code	Text	Enter the OSHA (Occupational Safety and Health Administration) Site Code.
City	Text	Enter the city of the reporting office.
State	ComboBox	Select the state of the reporting office from the dropdown list. WV KY NY VA IN MD NH VT WA RI AR MT WY MI TN WI ID IA FL SD NE MA MS SC MN GA NJ TX NM KS OR HI MO IL OH DC AL AK LA NV CO DE NC OK ND PA AZ UT CT CA ME
ZIP Code	Text	Enter the ZIP code of the reporting office. Maximum length is 5 characters. Max length: 5 characters
Compensation Details
25. Date pay stopped	Text	Enter the date when the employee's pay stopped.
Dependents Information
This field is a check box. Select this box if the employee has a spouse	CheckBox	Check this box if the employee has a spouse.
This field is a check box. Select this box if the employee has children under the age of 18	CheckBox	Check this box if the employee has children under the age of 18.
This field is a check box. Select this box if the employee has other dependents	CheckBox	Check this box if the employee has other dependents.
Employee Information
1. Name of employee (Last, First, Middle)	Text	Enter the full name of the employee, including last name, first name, and middle name.
2. Social Security Number	Text	Enter the employee's Social Security Number. This should be a 9-digit number. Max length: 9 characters
3. Date of birth	Text	Enter the employee's date of birth in the format MM/DD/YYYY.
5. Home telephone	Text	Enter the employee's home telephone number. This should be a 10-digit number. Max length: 10 characters
7. Employee's home mailing address (include street address, city, state, and ZIP code)	Text	Enter the employee's home mailing address, including street address, city, state, and ZIP code.
City	Text	Enter the city part of the employee's home mailing address.
State	ComboBox	Select the state part of the employee's home mailing address from the provided list. WV KY NY VA IN MD NH VT WA RI AR MT WY MI TN WI ID IA FL SD NE MA MS SC MN GA NJ TX NM KS OR HI MO IL OH DC AL AK LA NV CO DE NC OK ND PA AZ UT CT CA ME
ZIP Code	Text	Enter the ZIP code part of the employee's home mailing address. This should be a 5-digit number. Max length: 5 characters
12. Employee's occupation	Text	Enter the employee's occupation.
a. Occupation code	Text	Enter the occupation code.
b. Type code	Text	Enter the type code.
c. Source code	Text	Enter the source code.
The signature of the employee or person acting on behalf of the employee goes into this field	Text	Enter the signature of the employee or the person acting on behalf of the employee.
Date	Text	Enter the date when the employee signed the form.
1a. Email address	Text	Enter the email address of the employee.
4. Gender	ComboBox	Select the gender of the employee from the dropdown list. Transgender Female Non-Binary Male
18. Employee's duty station (include street address, city, state and ZIP code)	Text	Enter the employee's duty station address, including street address, city, state, and ZIP code.
City	Text	Enter the city of the employee's duty station.
State	ComboBox	Select the state of the employee's duty station from the dropdown list. WV KY NY VA IN MD NH VT WA RI AR MT WY MI TN WI ID IA FL SD NE MA MS SC MN GA NJ TX NM KS OR HI MO IL OH DC AL AK LA NV CO DE NC OK ND PA AZ UT CT CA ME
ZIP Code	Text	Enter the ZIP code of the employee's duty station. Maximum length is 5 characters. Max length: 5 characters
Identify in this field the employee's retirement coverage	Text	Identify the employee's retirement coverage in this field.
37. Pay rate when employee stopped work	Text	Enter the pay rate of the employee at the time they stopped working.
3a8f Per	Text	Specify the time period (e.g., per hour, per day) for the pay rate when the employee stopped work.
Employment Details
Enter into this field, the employee's grade level at the time of injury	Text	Enter the employee's grade level at the time of the injury.
Enter into this field, the employee's grade level step at the time of injury	Text	Enter the employee's grade level step at the time of the injury.
Form Actions
Print Form. Select this button or press the Enter Key to print the form	Button	Click this button or press the Enter key to print the form.
Save Form. Select this button or press the Enter Key to save the form	Button	Click this button or press the Enter key to save the form.
Reset Form. Select this button or press the Enter Key to reset the form	Button	Click this button or press the Enter key to reset the form.
Print Form. Select this button or press the Enter Key to print the form	Button	Press this button to print the form.
Save Form. Select this button or press the Enter Key to save the form	Button	Press this button to save the form.
Reset Form. Select this button or press the Enter Key to reset the form	Button	Press this button to reset the form.
Print Form. Select this button or press the Enter Key to print the form	Button	Press this button to print the form.
Save Form. Select this button or press the Enter Key to save the form	Button	Press this button to save the form.
Reset Form. Select this button or press the Enter Key to reset the form	Button	Press this button to reset the form.
Print Form. Select this button or press the Enter Key to print the form	Button	Press this button to print the form.
Save Form. Select this button or press the Enter Key to save the form	Button	Press this button to save the form.
Form Controls
Reset Form. Select this button or press the Enter Key to reset the form	Button	This button resets the entire form to its default state. Press this button if you need to clear all the information you have entered and start over.
General Information
form1[0].#subform[1].#area[2].RadioButtonList[1]_1	ComboBox	Select this option if applicable. This is part of a group of radio buttons.
form1[0].#subform[1].#area[2].RadioButtonList[1]_2	ComboBox	Select this option if applicable. This is part of a group of radio buttons.
form1[0].#subform[1].#area[3].RadioButtonList[2]_0	ComboBox	Select this option if applicable. This is part of a group of radio buttons.
form1[0].#subform[1].#area[3].RadioButtonList[2]_1	ComboBox	Select this option if applicable. This is part of a group of radio buttons.
form1[0].#subform[1].#area[4].RadioButtonList[3]_0	ComboBox	Select this option if applicable. This is part of a group of radio buttons.
form1[0].#subform[1].#area[4].RadioButtonList[3]_1	ComboBox	Select this option if applicable. This is part of a group of radio buttons.
Mo. Day Yr	Text	Enter the date in the format of Month, Day, Year.
Mo. Day Yr	Text	Enter the date in the format of Month, Day, Year.
Time	Text	Enter the time related to the injury or event.
form1[0].#subform[1].#area[6].RadioButtonList[4]_0	ComboBox	Select the appropriate option from the radio button list.
form1[0].#subform[1].#area[6].RadioButtonList[4]_1	ComboBox	Select the appropriate option from the radio button list.
Mo. Day Yr	Text	Enter the date in the format of Month, Day, Year.
Mo. Day Yr. 67a3	Text	Enter the date in the format of Month, Day, Year.
form1[0].#subform[1].#area[12].RadioButtonList[10]_0	ComboBox	Select this option if it applies to the question being asked in this section.
form1[0].#subform[1].#area[12].RadioButtonList[10]_1	ComboBox	Select this option if it applies to the question being asked in this section.
form1[0].#subform[1].#area[13].RadioButtonList[11]_0	ComboBox	Select this option if it applies to the question being asked in this section.
form1[0].#subform[1].#area[13].RadioButtonList[11]_1	ComboBox	Select this option if it applies to the question being asked in this section.
form1[0].#subform[1].#area[13].RadioButtonList[11]_2	ComboBox	Select this option if it applies to the question being asked in this section.
form1[0].#subform[1].#area[13].RadioButtonList[11]_3	ComboBox	Select this option if applicable. This is a radio button field.
Incident Details
Mo. Day Yr	Text	Enter the date of the incident in the format MM/DD/YYYY.
Injury Details
9. Place where injury occurred (e.g. 2nd floor, Main Post Office Bldg., 12th & Pine)	Text	Enter the specific location where the injury occurred, such as '2nd floor, Main Post Office Bldg., 12th & Pine'.
Mo. Day Yr	Text	Enter the date when the injury occurred in the format 'Month Day Year'.
Enter into this field, the time the injury occurred	Text	Enter the exact time when the injury occurred.
Mo. Day Yr	Text	Enter the date in the format 'Month Day Year'.
Describe in this field the cause of the injury; how it occurred and why	Text	Describe the cause of the injury, how it occurred, and why.
14. Nature of injury (identify both the injury and the part of the body, e.g., fracture of left leg)	Text	Describe the nature of the injury, including both the injury and the part of the body affected (e.g., fracture of left leg).
This field is a check box. Select this box for Wednesday	CheckBox	Check this box if the injury occurred on a Wednesday.
This field is a check box. Select this box for Thursday	CheckBox	Check this box if the injury occurred on a Thursday.
This field is a check box. Select this box for Friday	CheckBox	Check this box if the injury occurred on a Friday.
This field is a check box. Select this box for Saturday	CheckBox	Check this box if the injury occurred on a Saturday.
form1[0].#subform[1].#area[7].RadioButtonList[5]_0	ComboBox	Select this option if the employee was injured in the performance of duty.
form1[0].#subform[1].#area[7].RadioButtonList[5]_1	ComboBox	Select this option if the employee was not injured in the performance of duty.
form1[0].#subform[1].#area[8].RadioButtonList[6]_0	ComboBox	Select this option if the injury was caused by the employee's willful misconduct, intoxication, or intent to injure self or another.
form1[0].#subform[1].#area[8].RadioButtonList[6]_1	ComboBox	Select this option if the injury was not caused by the employee's willful misconduct, intoxication, or intent to injure self or another.
If you selected the NO check box, give an explanation about the employee NOT being injured in performance of duty	Text	Provide an explanation if the employee was not injured in the performance of duty.
form1[0].#subform[1].#area[9].RadioButtonList[7]_0	ComboBox	Select this option if the injury was caused by a third party.
form1[0].#subform[1].#area[9].RadioButtonList[7]_1	ComboBox	Select this option if the injury was not caused by a third party.
If you selected the YES check box, give an explanation about how the injury was caused by the employee's willful misconduct, intoxication, or intent to injure self or another	Text	Provide an explanation if the injury was caused by the employee's willful misconduct, intoxication, or intent to injure self or another.
form1[0].#subform[1].#area[10].RadioButtonList[8]_0	ComboBox	Select this option if the injury was caused by a specific event or series of events.
form1[0].#subform[1].#area[10].RadioButtonList[8]_1	ComboBox	Select this option if the injury was not caused by a specific event or series of events.
This acknowledges receipt of Notice of Injury sustained by (Name of injured employee)	Text	Enter the name of the injured employee to acknowledge receipt of the Notice of Injury.
Enter the date the Receipt of Notice of Injury was received, in the format of: MMMM D, YYYY (example: August 8, 2008). You can also select the date from the calendar icon by selecting the down arrow, or select the ALT Key plus the down arrow	Text	Enter the date the Receipt of Notice of Injury was received in the format MMMM D, YYYY (e.g., August 8, 2008). You can also select the date from the calendar icon.
At (Location)	Text	Enter the location where the injury occurred.
Location Details
City	Text	Enter the city where the injury occurred.
Medical Information
32. Name and address of physician first providing medical care (include street address, city, state, ZIP code)	Text	Provide the full name and address of the physician who first provided medical care, including street address, city, state, and ZIP code.
City	Text	Enter the city where the physician who first provided medical care is located.
State	ComboBox	Select the state where the physician who first provided medical care is located from the dropdown list. WV KY NY VA IN MD NH VT WA RI AR MT WY MI TN WI ID IA FL SD NE MA MS SC MN GA NJ TX NM KS OR HI MO IL OH DC AL AK LA NV CO DE NC OK ND PA AZ UT CT CA ME
ZIP Code	Text	Enter the ZIP code where the physician who first provided medical care is located. The ZIP code should be 5 digits long. Max length: 5 characters
Miscellaneous
form1[0].#subform[1].#area[2].RadioButtonList[1]_0	ComboBox	Select the appropriate option from the radio button list.
Return to Work Details
Enter the date the employee returned to work, in the format of: MMMM D, YYYY (example: August 8, 2008). You can also select the date from the calendar icon by selecting the down arrow, or select the ALT Key plus the down arrow	Text	Enter the date the employee returned to work in the format of: MMMM D, YYYY (example: August 8, 2008). You can also select the date from the calendar icon by selecting the down arrow, or select the ALT Key plus the down arrow.
Time	Text	Enter the time the employee returned to work.
Supervisor's Report
35. Does your knowledge of the facts about this injury agree with statements of the employee and/or witnesses	Text	Indicate whether your knowledge of the facts about this injury agrees with the statements of the employee and/or witnesses.
State in this field the reason why the employing agency controverts continuation of pay	Text	Provide the reason why the employing agency is disputing the continuation of pay.
Name of supervisor (Type or print)	Text	Type or print the name of the supervisor completing this section.
Date	Text	Enter the date when the supervisor completed this section.
Date fb88	Text	Enter the date associated with the supervisor's signature.
Supervisor's Title	Text	Enter the title of the supervisor completing this section.
Office phone	Text	Enter the office phone number of the supervisor. Maximum length is 10 digits. Max length: 10 characters
Signature of Official Superior	Text	Signature of the official superior.
Title	Text	Enter the title of the official superior.
Date (Mo. Day, Yr.)	Text	Enter the date in the format Mo. Day, Yr.
Third Party Information
Enter into this field the City of the third party	Text	Enter the city where the third party involved in the incident is located.
State	ComboBox	Select the state where the third party involved in the incident is located from the dropdown list. WV KY NY VA IN MD NH VT WA RI AR MT WY MI TN WI ID IA FL SD NE MA MS SC MN GA NJ TX NM KS OR HI MO IL OH DC AL AK LA NV CO DE NC OK ND PA AZ UT CT CA ME
ZIP Code	Text	Enter the ZIP code where the third party involved in the incident is located. The ZIP code should be 5 digits long. Max length: 5 characters
Witness Statement
16. Statement of witness (Describe what you saw, heard, or know about this injury)	Text	Provide a detailed statement describing what you saw, heard, or know about the injury.
Name of witness	Text	Enter the full name of the witness who observed the injury.
Signature of witness	Text	The witness should sign here to validate their statement.
Date signed	Text	Enter the date when the witness signed their statement.
Address	Text	Provide the address of the witness.
City	Text	Enter the city where the witness resides.
State	ComboBox	Select the state where the witness resides from the dropdown list. WV KY NY VA IN MD NH VT WA RI AR MT WY MI TN WI ID IA FL SD NE MA MS SC MN GA NJ TX NM KS OR HI MO IL OH DC AL AK LA NV CO DE NC OK ND PA AZ UT CT CA ME
ZIP Code	Text	Enter the ZIP Code of the witness's address. Maximum length is 5 characters. Max length: 5 characters
Work Schedule
Enter into this field, the employee's starting work hour time	Text	Enter the employee's starting work hour time in this field.
Enter into this field, the employee's ending work hour time	Text	Enter the employee's ending work hour time in this field.
This field is a check box. Select this box for Sunday	CheckBox	Select this box if the employee worked on Sunday.
This field is a check box. Select this box for Monday	CheckBox	Select this box if the employee worked on Monday.
This field is a check box. Select this box for Tuesday	CheckBox	Select this box if the employee worked on Tuesday.

Form CA-1, Federal Employee's Notice of Traumatic Injury Instructions