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Form CA-17, Duty Status Report, page 1
Complex · 65/100Form Complexity Index

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What this form asks for

The AI fills all of it, from your answers or your documents.

Form CA-17, Duty Status Report, is used to collect information about an employee's work status following an injury. It helps determine their ability to return to work and is crucial for processing workers' compensation claims.
Fillable fields165
Pages2
Sections62
Form Complexity IndexComplex, 65/100

The AI checks your answers before you download

24 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Ensures that the employee's full name is entered correctly on Side A in the format: last, first, middle.

This validation check ensures that the employee's full name is captured accurately on Side A of the Duty Status Report. It verifies that the name is entered in the prescribed format, which is the last name followed by a comma, the first name, and then the middle name or initial if applicable. The check is crucial for maintaining consistent records and ensuring that the employee's identity is correctly represented in official documents.

Confirms that the date of injury is provided on Side A in the correct format: month, day, year.

This validation check confirms that the date of injury is clearly stated on Side A of the Duty Status Report. It validates that the date is provided in the correct format, specifically month followed by day and year, ensuring that there is no ambiguity regarding the timeline of the injury. This is essential for tracking the incident accurately and is important for any follow-up actions or claims processing.

Verifies that the employee's Social Security Number is filled in accurately on Side A.

This validation check verifies that the employee's Social Security Number (SSN) is filled in accurately on Side A of the Duty Status Report. It checks that the SSN is complete and formatted correctly, typically as a nine-digit number without spaces or dashes. This information is critical for identification purposes and must be handled with care to protect the employee's privacy and security.

Checks that the employee's occupation is specified on Side A.

This validation check ensures that the employee's occupation is clearly specified on Side A of the Duty Status Report. It checks that the occupation field is not left blank and that the description provided is adequate to understand the nature of the employee's job. This information can be relevant when assessing the injury and its impact on the employee's ability to perform their work duties.

Validates the description of how the injury occurred and the parts of the body affected on Side A.

This validation check validates the description of how the injury occurred and which parts of the body were affected, as provided on Side A of the Duty Status Report. It ensures that the narrative is complete and provides sufficient detail to understand the circumstances of the injury. This is crucial for determining the cause and extent of the injury and for any necessary workplace safety improvements or compensation claims.

Confirms the number of hours per day and days per week the employee works as indicated on Side A.

The AI ensures that the employee's reported work schedule is accurately captured, including the total number of hours worked each day and the number of days worked per week. It cross-references this information with the details provided on Side A of the Duty Status Report to confirm consistency. Any discrepancies between the reported schedule and the form are flagged for review. This validation is crucial for maintaining accurate employment records and may have implications for wage calculations and benefits.

And 18 more checks
  • Ensures that the usual work requirements, including the number of hours per day for each activity, are detailed on Side A.
  • Verifies that the history of injury provided by the employee corresponds with the supervisor's account on Side B.
  • Checks for a complete description of clinical findings on Side B.
  • Ensures that all diagnosis(es) due to injury are listed on Side B.
  • Confirms if any other disabling conditions are noted on Side B.
  • Verifies whether the employee has been advised to resume work and the date advised if applicable on Side B.
  • Checks if the employee's ability to perform regular work is stated on Side B, including work type and hours per day.
  • Validates the inclusion of the date of examination and the date of the next appointment on Side B.
  • Ensures that the medical specialty is specified and the Tax Identification Number is filled in on Side B.
  • Physician's Signature and Date Presence on Side B
  • Supervisor Completion and Referral of Side A
  • Physician's Timely Completion and Return of Side B
  • Physician's Name and Address on Side B
  • Original Report Sent to OWCP/DFELHWC-FECA
  • Validates the physician's certification of the truthfulness and accuracy of the information by signing block 19.
  • Checks for compliance with the Privacy Act Statement and Public Burden Statement included in the form.
  • Ensures that any necessary accommodations for disability are communicated to OWCP as stated in the instructions.
  • Confirms that the form is not sent to the address provided for comments regarding the burden estimate.

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How to Fill Out CA-17 Online for Free in 2026

What the AI walks you through.

  1. Visit instafill.ai site and select CA-17.
  2. Enter employee's name and injury details.
  3. Complete work requirements and physician sections.
  4. Sign and date the form electronically.
  5. Check for accuracy and submit the form.

Common Mistakes in Completing CA-17

The ones the AI is built to catch.

Incomplete or illegible information in any field
One of the most common mistakes made when filling out a Duty Status Report is leaving fields incomplete or providing illegible information. This can lead to delays in processing and potential inaccuracies in the report. To avoid this mistake, ensure all required fields are fully completed and that all information is clear and legible. Double-check your entries to make sure they are complete and easy to read.
Incorrect Social Security Number entry
Another common mistake is entering an incorrect Social Security Number. This can lead to delays in processing and potential issues with tax reporting. To avoid this mistake, double-check your Social Security Number entry against your Social Security card or other official documentation. If you are unsure about your number, consult your employer or the Social Security Administration.
Misrepresentation of occupation
Misrepresenting your occupation on a Duty Status Report can lead to inaccurate reporting and potential consequences. It is important to provide an accurate and truthful description of your job duties. To avoid this mistake, carefully review the instructions for completing the occupation field and provide a detailed and accurate description of your job duties.
Vague or incomplete description of injury and body parts affected
Providing a vague or incomplete description of an injury and the body parts affected can lead to delays in processing and potential inaccuracies in the report. It is important to provide a clear and detailed description of any injuries sustained. To avoid this mistake, take the time to carefully describe the injury, including the date it occurred, the body parts affected, and the symptoms you are experiencing.
Inaccurate reporting of hours worked per day and week
Inaccurately reporting the hours worked per day and week can lead to potential issues with pay and potential consequences. It is important to provide an accurate and truthful report of your hours worked. To avoid this mistake, carefully review the instructions for reporting hours and keep accurate records of your hours worked.
Insufficient work requirements detail for each activity
When completing the Duty Status Report form, it is essential to provide a detailed description of the work requirements for each activity listed on Side A (a-t). Failure to do so may result in incomplete or inaccurate information. To avoid this mistake, take the time to carefully consider and document the specific duties, tasks, and responsibilities associated with each activity. This information should include the frequency, duration, and any physical or environmental demands.
Discrepancies between reported injury history and physician's findings
Another common mistake on the Duty Status Report form is the presence of discrepancies between the employee's reported history of injury and the physician's findings on Side B. These discrepancies can lead to confusion and potential misunderstandings. To prevent this issue, ensure that all information provided is accurate and consistent. Employees should report their injuries truthfully and in detail, while physicians should document their findings objectively and thoroughly. Communication between the employee and their healthcare provider is crucial to minimize discrepancies.
Failure to secure necessary signatures and dates
It is mandatory for both the supervisor and physician to sign and date the Duty Status Report form. Failure to obtain these signatures and dates may result in the form being rejected. To prevent this mistake, ensure that all necessary parties are aware of the requirement to sign and date the form and provide them with ample time to do so. Communication and organization are key to avoiding this issue.
Late submission of the form to the Employing Agency
Timely submission of the Duty Status Report form to the Employing Agency is crucial. Failure to do so may result in penalties or delays in processing. To prevent this mistake, familiarize yourself with the specified time frame for submission and ensure that the form is returned well before the deadline. Proper planning and organization can help avoid this issue.
Omission of the Employing Agency's address on Side A
Lastly, it is essential to include the correct address of the Employing Agency on Side A of the Duty Status Report form. Failure to do so may result in the form being misrouted or delayed. To prevent this mistake, double-check the address provided and ensure that it is accurate and complete. Clear communication with the Employing Agency can help minimize errors in this area.
Failure to send a copy of the report to the OWCP address provided
The Duty Status Report is required to be submitted to the Office of Workers' Compensation Programs (OWCP) for processing. Neglecting to send a copy of the completed report to the provided OWCP address may result in delays or denial of benefits. To avoid this mistake, ensure that you send a copy of the completed report to the OWCP address as soon as possible after submission to your supervisor. It is recommended to keep a record of the date and method of submission for your records.
Failure to fill in the Tax Identification Number on Side B
The Tax Identification Number (TIN) is required to be filled in on Side B of the Duty Status Report. Failing to provide this information may result in delays or denial of benefits. It is important to double-check that the TIN is entered correctly to ensure accurate processing of your report. To avoid this mistake, make sure to enter your correct TIN on Side B of the report before submitting it.
Failure to provide the date of the next appointment on Side B
The date of the next appointment is required to be filled in on Side B of the Duty Status Report. Failing to provide this information may result in delays or denial of benefits. It is important to ensure that the date provided is accurate and reflects the date of your next scheduled appointment. To avoid this mistake, make sure to enter the correct date of your next appointment on Side B of the report before submitting it.
Failure to specify the medical specialty on Side B
The medical specialty is required to be specified on Side B of the Duty Status Report. Failing to provide this information may result in delays or denial of benefits. It is important to ensure that the correct medical specialty is specified to ensure accurate processing of your report. To avoid this mistake, make sure to enter the correct medical specialty on Side B of the report before submitting it.
Failure to follow instructions for accommodations or modifications for employees with disabilities
The Duty Status Report may include instructions for accommodations or modifications for employees with disabilities. Failing to follow these instructions may result in denial of benefits or other negative consequences. It is important to carefully review and follow all instructions related to accommodations or modifications to ensure that you are meeting your obligations under the Americans with Disabilities Act (ADA) and other relevant laws. To avoid this mistake, make sure to carefully review and follow all instructions related to accommodations or modifications for employees with disabilities.

Frequently Asked Questions About CA-17

 

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How does the AI fill out CA-17?
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It is encrypted in transit and at rest, and it is never used to train AI.
How complex is CA-17 to fill out?
CA-17 has a Form Complexity Index of 65 out of 100, in the complex tier: 165 fillable fields across 2 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the purpose of the Duty Status Report (CA-17) form?
The Duty Status Report (CA-17) form is a document used to obtain a duty status report for an employee who has been injured. It is required by law and is utilized to determine eligibility for and the amount of benefits payable under the Federal Employees' Compensation Act.
Who should complete Side A of the Duty Status Report (CA-17) form?
Side A of the Duty Status Report (CA-17) form should be completed by the supervisor or employer of the injured employee.
Who should complete Side B of the Duty Status Report (CA-17) form?
Side B of the Duty Status Report (CA-17) form should be completed by the treating physician or healthcare provider of the injured employee.
What information is required on Side A of the Duty Status Report (CA-17) form?
Side A of the Duty Status Report (CA-17) form requires the following information about the injured employee: name, social security number, occupation, and work requirements. Additionally, it requires information about the injury itself, such as how it occurred and which body parts were affected.
What information is required on Side B of the Duty Status Report (CA-17) form?
Side B of the Duty Status Report (CA-17) form requires clinical findings and diagnoses from the treating physician, as well as information about any other disabling conditions the employee may have.
What is the OMB control number for the Duty Status Report (CA-17) form?
The OMB control number for the Duty Status Report (CA-17) form is 1240-0046.
Is the completion of the Duty Status Report (CA-17) form mandatory?
Yes, the completion of the Duty Status Report (CA-17) form is mandatory to obtain or retain a benefit under the Federal Employees' Compensation Act.
What happens if the information provided on the Duty Status Report (CA-17) form is found to be false or misleading?
Knowingly providing false or misleading information on the Duty Status Report (CA-17) form may subject the person certifying the information to criminal prosecution.
What should be done with the completed Duty Status Report (CA-17) form?
The completed Duty Status Report (CA-17) form should be sent to the Office of Workers' Compensation Programs, along with a copy for the employing agency.
What accommodations are available for individuals with disabilities when completing the Duty Status Report (CA-17) form?
Individuals with disabilities have the right to receive help from the OWCP in the form of communication assistance, accommodations, and modifications to aid them in the claims process. This may include alternate formats, sign language interpretation, or other adjustments or changes to accommodate their disability.
What is the deadline for completing and returning the Duty Status Report (CA-17) form?
The physician should return the completed Duty Status Report (CA-17) form to the employing agency within 2 days to prevent interruption of the employee's income.
What is the purpose of the Duty Status Report (CA-17) form?
The Duty Status Report (CA-17) form is used by physicians to report their duty status to their employing agency for compensation purposes under the Federal Employees' Compensation Act.
What information is required on the Duty Status Report (CA-17) form?
The Duty Status Report (CA-17) form requires the physician to provide their name, social security number, date of injury or death, nature of injury or cause of death, and the dates of their absence from work due to the injury or death.
What is the Privacy Act Statement for the Duty Status Report (CA-17) form?
The Privacy Act Statement for the Duty Status Report (CA-17) form notifies individuals that their personal information will be collected, used, and disclosed in accordance with the Federal Employees' Compensation Act and other relevant laws.
What is the Public Burden Statement for the Duty Status Report (CA-17) form?
The Public Burden Statement for the Duty Status Report (CA-17) form estimates the public reporting burden for this collection of information and provides instructions for submitting comments regarding the burden estimate.
Is the Duty Status Report (CA-17) form mandatory?
Yes, the Duty Status Report (CA-17) form is mandatory for physicians to file with their employing agency in order to receive compensation benefits under the Federal Employees' Compensation Act.
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