Form CA-17, Duty Status Report Completed Form Examples and Samples
Explore a detailed example of a filled Form CA-17, Duty Status Report. This sample is tailored for an injury leave case, showcasing how to accurately complete the form with necessary employee, injury, and medical details. Perfect for employers and employees navigating the process of injury leave.
Form CA-17 Example – Injury Leave Case
How this form was filled:
The form includes the employee's personal and injury details, the physician's assessment of their duty status, and the duration of the anticipated recovery. It is important for both the employer and employee to fill out the pertinent sections completely and accurately.
Information used to fill out the document:
- Employee's Name: Jane Smith
- Employee's Job Title: Warehouse Worker
- Injury Description: Lower back strain
- Injury Date: 2025-05-18
- Employer's Name: ABC Logistics
- Physician's Name: Dr. John Brown
- Duty Restrictions: No lifting over 10 lbs
- Expected Duration of Restriction: 2 weeks
- Assessment Date: 2025-05-19
What this filled form sample shows:
- Accurate employee and employer identification details
- Comprehensive injury description and date
- Clear physician’s assessment and duty restrictions
- Specific duration of activity limitations
Form specifications and details:
| Use Case: | Employee going on injury leave |
| Relevance: | Essential for processing work-related injury claims |
| Required Parties: | Employee, Employer, Physician |
| Importance: | Ensures employee receives appropriate work accommodations |
