Form CA-17, Duty Status Report Instructions
This form contains 165 fields organized into 62 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Clinical Findings Description | ||
| Clinical Findings Description | Text |
Provide a detailed description of the clinical findings related to the injury.
|
| Date of Injury | ||
| Date of Injury | Date |
Enter the date the injury occurred.
|
| Diagnosis Due to Injury | ||
| Diagnosis Due to Injury 1 | Text |
Enter the first diagnosis or medical condition resulting from the injury.
|
| Employee Advised to Resume Work | ||
| Date Advised to Resume Work | Date |
Enter the date the employee was advised to resume work.
|
| form1[0].Page1[0].SideB[0].ResumeWork[0].RegularWorkYN[1]_0 | Combobox |
Select 'Yes' if the employee is advised to resume regular work, otherwise select 'No'.
|
| form1[0].Page1[0].SideB[0].ResumeWork[0].RegularWorkYN[1]_1 | Combobox |
Select 'No' if the employee is not advised to resume regular work, otherwise select 'Yes'.
|
| Employee Work Schedule | ||
| Hours Per Day | Number |
Enter the number of hours the employee works per day.
|
| Days Per Week | Number |
Enter the number of days the employee works per week.
|
| Employee's Ability to Perform Regular Work | ||
| form1[0].Page1[0].SideB[0].RegularWork13[0].RegularWorkYN[0]_0 | Combobox |
Select 'Yes' if the employee is able to perform regular work.
|
| form1[0].Page1[0].SideB[0].RegularWork13[0].RegularWorkYN[0]_1 | Combobox |
Indicate whether the employee is able to perform regular work duties.
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| form1[0].Page1[0].SideB[0].RegularWork13[0].FullTimePartTime[0]_0 | Combobox |
Specify if the employee is able to work full-time.
|
| form1[0].Page1[0].SideB[0].RegularWork13[0].FullTimePartTime[0]_1 | Combobox |
Specify if the employee is able to work part-time.
|
| Part-Time Hours Per Day | Number |
Enter the number of hours per day the employee is able to work if working part-time.
|
| Employee's Name | ||
| Employee's Middle Name | Text |
Enter the employee's middle name.
|
| Employee's First Name | Text |
Enter the employee's first name.
|
| Employee's Last Name | Text |
Enter the employee's last name.
|
| Employing Agency Address | ||
| Employing Agency Address Line 1 | Text |
Enter the street address for the employing agency.
|
| Employing Agency City | Text |
Enter the city for the employing agency's address.
|
| Employing Agency State | Combobox |
Enter the state for the employing agency's address.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|
| Employing Agency Zip Code | Text |
Enter the zip code for the employing agency's address.
|
| Form Actions | ||
| Print form | Button |
Click this button to print the form.
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| Reset form | Button |
Click this button to reset the form to its default state.
|
| History of Injury Correspondence | ||
| Injury History Discrepancy Description | Text |
Provide details if the history of injury given by the employee does not correspond to what is shown in Item 5.
|
| form1[0].Page1[0].SideB[0].InjuryHistory8[0].InjuryHistoryYN[0]_0 | Combobox |
Select 'Yes' if there is a history of the injury.
|
| form1[0].Page1[0].SideB[0].InjuryHistory8[0].InjuryHistoryYN[0]_1 | Combobox |
Select 'No' if there is no history of the injury.
|
| Injury Occurrence Description | ||
| Injury Occurrence Description | Text |
Provide a detailed description of how the injury occurred and which parts of the body were affected.
|
| Interpersonal Relations Affectation | ||
| form1[0].Page1[0].SideB[0].Neuro14[0].NeuroYN[0]_0 | Combobox |
Indicate whether there are any neurological findings related to the employee's injury.
|
| form1[0].Page1[0].SideB[0].Neuro14[0].NeuroYN[0]_1 | Combobox |
Indicate whether there are no neurological findings related to the employee's injury.
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| Interpersonal Relations Not Affected Description | Text |
Provide a description if interpersonal relations are not affected due to a neuropsychiatric condition.
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| Medical Facility Name and Address | ||
| Medical Facility Name | Text |
Enter the full name of the medical facility.
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| Medical Facility Street Address | Text |
Provide the street number and name of the medical facility's physical address.
|
| Medical Facility City | Combobox |
Enter the city of the medical facility's address.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|
| Medical Facility State | Text |
Provide the state of the medical facility's address.
|
| Occupation | ||
| Occupation | Text |
Please enter the employee's occupation.
|
| Other Disabling Conditions | ||
| Other Disabling Conditions | Text |
Provide a description of any other disabling conditions not previously listed.
|
| Other Usual Work Requirements Description | ||
| Other Usual Work Requirement Description | Text |
Provide a description of any other usual work requirements not listed in the provided categories.
|
| OWCP File Number | ||
| OWCP File Number | Text |
Provide the OWCP File Number if known.
|
| Physician Administrative Details | ||
| 15. Date of Examination | Date |
Enter the date of the examination.
|
| 16. Date of Next Appointment | Date |
Enter the date of the next appointment.
|
| 17. Specialty | Text |
Enter the physician's medical specialty.
|
| 18. Tax Identification Number | Number |
Enter the physician's tax identification number.
|
| 20. Date of Signature | Date |
Enter the date the physician signed the form.
|
| Physician's Address | ||
| Enter name | Text |
Enter the name of the physician.
|
| Enter street address | Text |
Enter the street address of the physician's office.
|
| Physician's Assessment | ||
| Enter range in degrees F | Text |
Enter the range of temperatures in degrees Fahrenheit that the employee can work in.
|
| Enter range in degrees F | Text |
Enter the range of temperatures in degrees Fahrenheit that the employee can work in.
|
| Report Address | ||
| Enter name | Text |
Enter the name of the person or entity to whom the report is addressed.
|
| Enter street address | Text |
Enter the street address for the report address.
|
| Social Security Number | ||
| Social Security Number | Text |
Please provide the employee's Social Security Number.
|
| Usual Work Requirements for Bending/Stooping | ||
| Bending/Stooping - Continuous | Checkbox |
Check this box if the employee's usual work requires continuous bending/stooping.
|
| Bending/Stooping - Intermittent | Checkbox |
Check this box if the employee's usual work requires intermittent bending/stooping.
|
| Intermittent Bending/Stooping Hours Per Day | Number |
Enter the number of hours per day the employee performs bending or stooping intermittently.
|
| Usual Work Requirements for Chemicals/Solvents | ||
| Chemicals/Solvents - Continuous | Checkbox |
Check this box if the employee's usual work continuously involves exposure to chemicals, solvents, or similar substances.
|
| Chemicals/Solvents - Intermittent | Checkbox |
Check this box if the employee's usual work intermittently involves exposure to chemicals, solvents, or similar substances.
|
| Intermittent Chemicals/Solvents Hours Per Day | Number |
Enter the number of hours per day the employee is intermittently exposed to chemicals, solvents, etc.
|
| Usual Work Requirements for Climbing | ||
| Climbing - Continuous | Checkbox |
Check this box if the employee performs climbing continuously as part of their usual work requirements.
|
| Climbing - Intermittent | Checkbox |
Check this box if the employee performs climbing intermittently as part of their usual work requirements.
|
| Intermittent Climbing Hours Per Day | Number |
Enter the number of hours per day the employee performs climbing activities on an intermittent basis.
|
| Usual Work Requirements for Driving a Vehicle | ||
| Driving a Vehicle Continuous | Checkbox |
Check this box if the employee's usual work requirements involve driving a vehicle continuously.
|
| Driving a Vehicle Intermittent | Checkbox |
Check this box if the employee's usual work requirements involve driving a vehicle intermittently.
|
| Driving a Vehicle Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee intermittently drives a vehicle.
|
| Usual Work Requirements for Fine Manipulation | ||
| Fine Manipulation Continuous | Checkbox |
Check this box if the employee's usual work requirements include continuous fine manipulation (including keyboarding).
|
| Fine Manipulation Intermittent | Checkbox |
Check this box if the employee's usual work requirements include intermittent fine manipulation (including keyboarding).
|
| Intermittent Fine Manipulation Hours Per Day | Number |
Enter the number of hours per day the employee performs fine manipulation intermittently.
|
| Usual Work Requirements for Fumes/Dust | ||
| Fumes/Dust Continuous Exposure | Checkbox |
Check this box if the employee's work continuously exposes them to fumes or dust.
|
| Fumes/Dust Intermittent Exposure | Checkbox |
Check this box if the employee's work intermittently exposes them to fumes or dust.
|
| Intermittent Fumes Dust Hours Per Day | Number |
Enter the number of hours per day the employee is intermittently exposed to fumes or dust.
|
| Usual Work Requirements for High Humidity | ||
| High Humidity Continuous | Checkbox |
Check this box if the employee's usual work requirements involve continuous exposure to high humidity.
|
| High Humidity Intermittent | Checkbox |
Check this box if the employee's usual work requirements involve intermittent exposure to high humidity.
|
| Intermittent High Humidity Hours Per Day | Number |
Specify the number of hours per day the employee is intermittently exposed to high humidity.
|
| Usual Work Requirements for Kneeling | ||
| Kneeling Continuous | Checkbox |
Check this box if the employee's usual work requirements involve continuous kneeling.
|
| Kneeling Intermittent | Checkbox |
Check this box if the employee's usual work requirements involve intermittent kneeling.
|
| Kneeling Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee intermittently performs kneeling.
|
| Usual Work Requirements for Lifting/Carrying | ||
| Lifting/Carrying Continuous Max Weight | Number |
Enter the maximum weight in pounds that can be continuously lifted or carried.
|
| Lifting/Carrying Intermittent Max Weight | Number |
Enter the maximum weight in pounds that can be intermittently lifted or carried.
|
| Lifting/Carrying Intermittent Hours Per Day | Number |
Enter the number of hours per day for intermittent lifting or carrying.
|
| Usual Work Requirements for Noise | ||
| Continuous Noise Exposure | Checkbox |
Check this box if the employee is continuously exposed to noise as part of their usual work requirements.
|
| Intermittent Noise Exposure | Checkbox |
Check this box if the employee is intermittently exposed to noise as part of their usual work requirements.
|
| Continuous Noise dBA Level | Number |
Enter the continuous noise level in decibels (dBA) the employee is exposed to.
|
| Usual Work Requirements for Operating Machinery | ||
| Continuous Operating Machinery | Checkbox |
Check this box if operating machinery is a continuous work requirement for the employee.
|
| Intermittent Operating Machinery | Checkbox |
Check this box if operating machinery is an intermittent work requirement for the employee.
|
| Intermittent Operating Machinery Hours Per Day | Number |
Enter the number of hours per day the employee intermittently operates machinery.
|
| Usual Work Requirements for Pulling/Pushing | ||
| Pulling/Pushing - Continuous | Checkbox |
Check this box if the employee's usual work requires continuous pulling or pushing.
|
| Pulling/Pushing - Intermittent | Checkbox |
Check this box if the employee's usual work requires intermittent pulling or pushing.
|
| Intermittent Pulling/Pushing Hours Per Day | Number |
Enter the number of hours per day the employee performs pulling or pushing activities intermittently.
|
| Usual Work Requirements for Reaching above Shoulder | ||
| Continuous Reaching above Shoulder | Checkbox |
Check this box if the employee's work continuously requires reaching above shoulder height.
|
| Intermittent Reaching above Shoulder | Checkbox |
Check this box if the employee's work intermittently requires reaching above shoulder height.
|
| Intermittent Reaching above Shoulder Hours Per Day | Number |
Enter the number of hours per day the employee intermittently performs reaching above shoulder activities.
|
| Usual Work Requirements for Simple Grasping | ||
| Simple Grasping Continuous | Checkbox |
Check this box if the employee's usual work requires continuous simple grasping.
|
| Simple Grasping Intermittent | Checkbox |
Check this box if the employee's usual work requires intermittent simple grasping.
|
| Simple Grasping Continuous Hours Per Day | Number |
Enter the number of hours per day the employee continuously performs simple grasping tasks.
|
| Usual Work Requirements for Sitting | ||
| Sitting Continuous | Checkbox |
Check this box if the employee's usual work requirement involves continuous sitting.
|
| Sitting Intermittent | Checkbox |
Check this box if the employee's usual work requirement involves intermittent sitting.
|
| Sitting Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee is intermittently required to sit.
|
| Usual Work Requirements for Standing | ||
| Standing Continuous | Checkbox |
Check this box if the employee's usual work requirements involve standing continuously.
|
| Standing Intermittent | Checkbox |
Check this box if the employee's usual work requirements involve standing intermittently.
|
| Intermittent Standing Hours Per Day | Number |
Enter the number of hours the employee is intermittently standing per day.
|
| Usual Work Requirements for Temp. Extremes | ||
| Temp. Extremes Continuous | Checkbox |
Check this box if the employee's usual work continuously involves exposure to temperature extremes.
|
| Temp. Extremes Intermittent | Checkbox |
Check this box if the employee's usual work intermittently involves exposure to temperature extremes.
|
| Intermittent Temp. Extremes Range | Text |
Enter the intermittent temperature extremes range in degrees Fahrenheit.
|
| Usual Work Requirements for Twisting | ||
| Twisting Continuous | Checkbox |
Check if the employee performs twisting continuously.
|
| Twisting Intermittent | Checkbox |
Check if the employee performs twisting intermittently.
|
| Twisting Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee performs twisting intermittently.
|
| Usual Work Requirements for Walking | ||
| Walking Continuous | Checkbox |
Check this box if the employee's usual work requires walking continuously.
|
| Walking Intermittent | Checkbox |
Check this box if the employee's usual work requires walking intermittently.
|
| Walking Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee performs walking intermittently.
|
| Work Capabilities | ||
| Enter range in degrees F | Text |
Enter the range of temperature in degrees Fahrenheit that the employee can work in.
|
| Work Environment | ||
| Enter range in degrees F | Text |
Enter the temperature range in degrees Fahrenheit that the employee is exposed to during work.
|
| Work Performance Limitations for Bending/Stooping | ||
| Continuous Bending/Stooping | Checkbox |
Check this box if the employee performs bending/stooping continuously.
|
| Intermittent Bending/Stooping | Checkbox |
Check this box if the employee performs bending/stooping intermittently.
|
| Intermittent Bending/Stooping Hours Per Day | Number |
Enter the number of hours per day the employee can intermittently perform bending or stooping activities.
|
| Work Performance Limitations for Chemicals/Solvents | ||
| Chemicals/Solvents Continuous | Checkbox |
Check this box if the employee's work involves continuous exposure to chemicals, solvents, etc.
|
| Chemicals/Solvents Intermittent | Checkbox |
Check this box if the employee's work involves intermittent exposure to chemicals, solvents, etc.
|
| Chemicals/Solvents Hours Per Day | Number |
Enter the number of hours per day the employee is exposed to chemicals or solvents.
|
| Work Performance Limitations for Climbing | ||
| Climbing Continuous | Checkbox |
Check this box if the employee performs climbing continuously as part of their usual work requirements.
|
| Climbing Intermittent | Checkbox |
Check this box if the employee performs climbing intermittently as part of their usual work requirements.
|
| Climbing Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee can perform climbing intermittently.
|
| Work Performance Limitations for Driving a Vehicle | ||
| Driving a Vehicle Continuously | Checkbox |
Check this box if the employee's work performance requires continuous driving of a vehicle.
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| Driving a Vehicle Intermittently | Checkbox |
Check this box if the employee's work performance requires intermittent driving of a vehicle.
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| Driving a Vehicle Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee can intermittently drive a vehicle.
|
| Work Performance Limitations for Fine Manipulation | ||
| Fine Manipulation (Continuous) | Checkbox |
Check this box if the employee's fine manipulation (including keyboarding) is continuous.
|
| Fine Manipulation (Intermittent) | Checkbox |
Check this box if the employee's fine manipulation (including keyboarding) is intermittent.
|
| Intermittent Fine Manipulation Hrs/Day | Number |
Enter the number of hours per day the employee can intermittently perform fine manipulation tasks, including keyboarding.
|
| Work Performance Limitations for Fumes/Dust | ||
| Fumes/Dust - Continuous | Checkbox |
Check this box if the employee is exposed to fumes or dust continuously.
|
| Fumes/Dust - Intermittent | Checkbox |
Check this box if the employee is exposed to fumes or dust intermittently.
|
| Intermittent Fumes/Dust Hours Per Day | Text |
Enter the number of hours per day the employee is intermittently exposed to fumes or dust.
|
| Work Performance Limitations for High Humidity | ||
| High Humidity Continuous | Checkbox |
Check this box if high humidity impacts the employee's work performance on a continuous basis.
|
| High Humidity Intermittent | Checkbox |
Check this box if high humidity impacts the employee's work performance on an intermittent basis.
|
| Intermittent High Humidity Hours Per Day | Number |
Enter the number of intermittent hours per day the employee has work performance limitations due to high humidity.
|
| Work Performance Limitations for Kneeling | ||
| Kneeling - Continuous | Checkbox |
Check this box if the employee's kneeling activity is continuous.
|
| Kneeling - Intermittent | Checkbox |
Check this box if the employee's kneeling activity is intermittent.
|
| Kneeling Hours Per Day | Number |
Enter the number of hours per day the employee is able to perform kneeling.
|
| Work Performance Limitations for Lifting/Carrying | ||
| Continuous Lifting/Carrying Maximum Weight | Number |
Enter the maximum weight that can be continuously lifted or carried.
|
| Intermittent Lifting/Carrying Maximum Weight | Number |
Enter the maximum weight that can be intermittently lifted or carried.
|
| Intermittent Lifting/Carrying Hours Per Day | Number |
Enter the number of hours per day the employee can intermittently lift or carry.
|
| Work Performance Limitations for Noise | ||
| Noise (Give dBA) - Continuous | Checkbox |
Check this box if the employee's work performance is continuously limited by noise exposure, specifying the dBA level and hours per day.
|
| Noise (Give dBA) - Intermittent | Checkbox |
Check this box if the employee's work performance is intermittently limited by noise exposure, specifying the dBA level and hours per day.
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| Intermittent Noise dBA Level | Number |
Enter the intermittent decibel A-weighted (dBA) level for noise exposure.
|
| Work Performance Limitations for Operating Machinery | ||
| Continuous Operating Machinery | Checkbox |
Check this box if the employee's limitation for operating machinery is continuous.
|
| Intermittent Operating Machinery | Checkbox |
Check this box if the employee's limitation for operating machinery is intermittent.
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| Intermittent Operating Machinery Hours Per Day | Number |
Enter the number of hours per day the employee intermittently operates machinery.
|
| Work Performance Limitations for Pulling/Pushing | ||
| Pulling/Pushing - Continuous | Checkbox |
Check this box if the employee's usual work requirements include continuous pulling or pushing.
|
| Pulling/Pushing - Intermittent | Checkbox |
Check this box if the employee's usual work requirements include intermittent pulling or pushing.
|
| Pulling/Pushing Intermittent Hours Per Day | Number |
Specify the number of hours per day the employee can intermittently perform pulling or pushing tasks.
|
| Work Performance Limitations for Reaching above Shoulder | ||
| Reaching above Shoulder - Continuous | Checkbox |
Check this box if the employee continuously performs work that involves reaching above the shoulder.
|
| Reaching above Shoulder - Intermittent | Checkbox |
Check this box if the employee intermittently performs work that involves reaching above the shoulder.
|
| Reaching above Shoulder Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee can intermittently perform reaching above shoulder.
|
| Work Performance Limitations for Simple Grasping | ||
| Simple Grasping Continuous Limitation | Checkbox |
Check this box if the employee's ability to perform simple grasping is continuously limited.
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| Simple Grasping Intermittent Limitation | Checkbox |
Check this box if the employee's ability to perform simple grasping is intermittently limited.
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| Simple Grasping Intermittent Hours | Number |
Enter the number of hours per day the employee can perform simple grasping intermittently.
|
| Work Performance Limitations for Sitting | ||
| Sitting - Continuous | Checkbox |
Check this box if the employee's work performance requires sitting continuously.
|
| Sitting - Intermittent | Checkbox |
Check this box if the employee's work performance requires sitting intermittently.
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| Intermittent Sitting Hours Per Day | Number |
Specify the number of hours per day the employee can intermittently sit.
|
| Work Performance Limitations for Standing | ||
| Standing Continuous | Checkbox |
Check this box if the employee's work performance limitations require them to stand continuously.
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| Standing Intermittent | Checkbox |
Check this box if the employee's work performance limitations require them to stand intermittently.
|
| Standing Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee can intermittently stand.
|
| Work Performance Limitations for Temp. Extremes | ||
| Continuous Exposure to Temperature Extremes | Checkbox |
Check this box if the employee is continuously exposed to temperature extremes as part of their work requirements.
|
| Intermittent Exposure to Temperature Extremes | Checkbox |
Check this box if the employee is intermittently exposed to temperature extremes as part of their work requirements.
|
| Intermittent Temperature Extremes Range | Text |
Specify the temperature range in degrees Fahrenheit for intermittent exposure to temperature extremes.
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| Work Performance Limitations for Twisting | ||
| Twisting Continuous | Checkbox |
Check if the employee performs twisting activities continuously.
|
| Twisting Intermittent | Checkbox |
Check if the employee performs twisting activities intermittently.
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| Twisting Intermittent Hours Per Day | Number |
Enter the number of hours per day the employee performs twisting intermittently.
|
| Work Performance Limitations for Walking | ||
| Walking Continuous | Checkbox |
Check this box if the employee's work performance limitation for walking is continuous.
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| Walking Intermittent | Checkbox |
Check this box if the employee's work performance limitation for walking is intermittent.
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| Continuous Walking Hours Per Day | Number |
Enter the continuous hours per day the employee can perform walking activity.
|