Form CA-17, Duty Status Report (U.S. Department of Labor, Office of Workers' Compensation Programs) Completed Form Examples and Samples

Browse a realistic Form CA-17 (Duty Status Report) example from the U.S. Department of Labor, Office of Workers' Compensation Programs (OWCP). This filled sample shows a light-duty return-to-work scenario after a shoulder strain, including objective findings, diagnosis, treatment plan, work restrictions (lifting limits, no overhead work, limited pushing/pulling), restriction dates, and follow-up evaluation—useful as a reference for completing CA-17 forms.

Form CA-17 Example – Light-Duty Return to Work After Shoulder Strain

How this form was filled:

This Form CA-17 (Duty Status Report) example shows a federal employee with a right shoulder strain who can return to work on temporary light duty. The sample includes recent 2026 dates, the job’s physical demands, objective findings, diagnosis, treatment plan, and clear restrictions (no lifting over 10 lbs, no overhead work, limited pushing/pulling). It also documents the expected duration of restrictions and follow-up evaluation.

Information used to fill out the document:

  • Form Name: CA-17, Duty Status Report
  • Agency / Employer: U.S. Postal Service (USPS)
  • Employing Office / Facility: Riverview Post Office – Delivery Unit
  • Employing Office Address: 250 Riverfront Ave, Riverview, VA 23220
  • OWCP Case Number: 12-3456789
  • Employee Full Name: Avery J. Morgan
  • Employee Date of Birth: 08/14/1989
  • Employee Phone Number: (804) 555-0172
  • Employee Mailing Address: 1186 Parkline Dr, Riverview, VA 23221
  • Job Title: City Carrier Assistant
  • Work Schedule: Mon–Fri, 7:30 AM–4:00 PM
  • Injury Date: 11/18/2025
  • Date of Examination: 01/06/2026
  • Date CA-17 Prepared: 01/06/2026
  • Injury Description: Right shoulder pain after lifting and carrying mail trays; felt a sharp pull while loading a vehicle
  • Mechanism of Injury: Overexertion while lifting a mail tray from waist to shoulder height
  • Objective Findings: Right shoulder tenderness over anterior deltoid; decreased active range of motion; positive Hawkins-Kennedy impingement sign; strength 4/5 abduction due to pain
  • Diagnosis: Right shoulder strain with rotator cuff tendinopathy (work-related)
  • ICD-10 Codes: S46.011A; M75.81
  • Imaging / Tests: X-ray (12/02/2025) negative for fracture/dislocation
  • Current Medications: Naproxen 500 mg twice daily with food as needed for 10 days
  • Treatment Provided: Activity modification, home exercise program, referral to physical therapy
  • Physical Therapy Plan: PT 2x/week for 4 weeks focusing on ROM and rotator cuff strengthening
  • Work Capacity Determination: Employee is able to work with restrictions (temporary light duty)
  • Work Restrictions Start Date: 01/06/2026
  • Work Restrictions End / Re-evaluation Date: 02/03/2026
  • Lifting/Carrying Limit: Up to 10 lbs occasionally; no repetitive lifting
  • Pushing/Pulling Limit: Max 15 lbs; avoid forceful pushing/pulling
  • Overhead Work: No overhead reaching with right arm
  • Repetitive Use: Limit repetitive right shoulder motion to <30 minutes per hour
  • Climbing / Ladders: No ladder climbing
  • Driving: Permitted; avoid repetitive shoulder-height loading tasks
  • Other Restrictions: No use of vibrating tools with right arm
  • Recommended Light-Duty Tasks: Sorting mail at waist height, administrative scanning tasks, counter support tasks without overhead reaching
  • Is Employee Disabled from Work?: No
  • Is Employee Capable of Modified Duty?: Yes
  • Follow-up Appointment Date: 02/03/2026
  • Physician Name: Dr. Elena K. Patel, MD
  • Physician Specialty: Occupational Medicine
  • Physician Phone: (804) 555-0139
  • Physician Address: North River Occupational Health, 940 Westgate Blvd, Riverview, VA 23222
  • Physician Signature (Typed): Elena K. Patel, MD
  • Physician Signature Date: 01/06/2026

What this filled form sample shows:

  • SEO-focused Form CA-17, Duty Status Report (U.S. Department of Labor, Office of Workers' Compensation Programs) example with realistic 2026 dates
  • Clear return-to-work status showing the employee can work with temporary light-duty restrictions
  • Detailed objective findings, diagnosis, and testing to support work restrictions
  • Specific physical limitations (lifting, pushing/pulling, overhead reaching, repetitive use) written in measurable terms
  • Practical light-duty task suggestions aligned with common federal work settings (USPS delivery unit)
  • Defined restriction timeframe with a scheduled re-evaluation date for OWCP documentation

Form specifications and details:

Form: Form CA-17
Agency: U.S. Department of Labor (DOL)
Program Office: Office of Workers' Compensation Programs (OWCP)
Purpose: Duty Status Report documenting medical findings and work capacity/restrictions for a work-related injury
Use Case: Temporary light-duty return to work after right shoulder strain/rotator cuff tendinopathy
Example Type: Completed sample data for web rendering (non-official, illustrative)
Jurisdiction: United States (Federal workers' compensation)
Date Range Emphasis: Dates set near 2026 for a current, realistic example

Created: January 16, 2026 06:10 AM

Download PDF Example
Completed Form CA-17 Duty Status Report example showing temporary work restrictions and a light-duty assignment for a federal employee