Duty Status Report

• Legal Form Number: CA-17
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

OWCP File Number

(If known)

Duty Status Report U.S. Department of Labor

Office of Workers' Compensation Programs

This form is provided for the purpose of obtaining a duty status report for the employee named below. This request

does not constitute authorization for payment of medical expense by the Department of Labor, nor does it invalidate any previous

authorization issued in this case. This request for information is authorized by law (5 USC 8101 et seq.) and is required to obtain

or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the

Privacy Act of 1974 and the OMB Cir. A-130. Persons are not required to respond to this collection of information unless it

displays a currently valid OMB control number.

OMB No. 1240-0046

Expires: 08/31/2026

SIDE A - Supervisor: Complete this side and refer to physician

1. Employee's Name (Last, first, middle)

2. Date of Injury (Month, day, yr.) 3. Social Security Number

4. Occupation

5. Describe How the Injury Occurred and State Parts of the Body Affected

6. The Employee Works

Hours Per Day Days Per Week

7. Specify the Usual Work Requirements of the Employee. Check

Whether Employee Performs These Tasks or is Exposed Continuously

or intermittently, and Give Number of Hours.

Activity Continuous Intermittent

a. Lifting/Carrying:

State Max Wt.

#Ibs. #Ibs.

Hrs Per Day

b. Sitting Hrs Per Day

c. Standing Hrs Per Day

d. Walking Hrs Per Day

e. Climbing Hrs Per Day

f. Kneeling Hrs Per Day

g. Bending/Stooping Hrs Per Day

h. Twisting Hrs Per Day

i. Pulling/Pushing Hrs Per Day

j. Simple Grasping Hrs Per Day

k. Fine Manipulation

(includes keyboarding) Hrs Per Day

l. Reaching above

Shoulder Hrs Per Day

m. Driving a Vehicle

(Specify) Hrs Per Day

n. Operating Machinery

(Specify) Hrs Per Day

o. Temp. Extremes

range in degrees F

p. High Humidity Hrs Per Day

q. Chemicals, Solvents,

etc. (Identify) Hrs Per Day

r. Fumes/Dust (identify) Hrs Per Day

s. Noise (Give dBA)

dBA

Hrs Per Day

t. Other (Describe)

SIDE B - Physician: Complete this side

Continuous Intermittent

#Ibs. #Ibs.

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

Hrs Per Day

range in degrees F

Hrs Per Day

Hrs Per Day

Hrs Per Day

dBA

Hrs Per Day

8. Does the History of Injury Given to You by the Employee

Correspond to that Shown in Item 5? Yes No (If not, describe)

9. Description of Clinical Findings

10.Diagnosis(es) Due to Injury 11. Other Disabling Conditions

12. Employee Advised to Resume Work?

13. Employee Able to Perform Regular Work Described on Side A?

Yes, If so

No, If not, complete below:

Full-Time or Part-Time Hrs Per Day

14. Are Interpersonal Relations Affected Because of a Neuropsychiatric Condition?

(e.g. Ability to Give or Take Supervision, Meet Deadlines, etc.)

Yes No (Describe)

15. Date of Examination 16. Date of Next Appointment

17. Specialty 18. Tax Identification Number

19. Physician's Signature 20. Date

Yes, Date Advised No

If you have a disability and are in need of communication assistance (such as

alternate formats or sign language interpretation), accommodations and/or

modifications, please contact OWCP. See form instructions for Requests for

Accommodations or Auxiliary Aids and Services CA-17 (Rev. 04/2020)

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