Rehabilitation Maintenance Certificate

• Legal Form Number: OWCP-17
• Issuer: Office of Workers' Compensation Programs
• Section: U.S. Department of Labor

Rehabilitation Maintenance Certificate U.S. Department of Labor

Office of Workers' Compensation Programs

IMPORTANT: No monies or benefits can be paid under this program unless this report is completed and filed as requested by

law (5 U.S.C. 8111;33 U.S.C. 901 as extended and amended). The information collected will be handled and stored in

compliance with the Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 130.

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 additional guidance below for REQUESTS FOR

ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.

OMB No.1240-0012

Expires: 04/30/2025

1. Name of Injured Worker (First, Middle Initial, Last) 2. OWCP No.

3. Complete Mailing Address (No., Street, City, State, ZIP Code)

Address Line 1

Address Line 2

City State ZIP

4. Maintenance Payment Per Week

$

5. Maintenance Pay Period (Month, Day, Year)

From Thru Federal Employees' Compensation Act

Longshore and Harbor Workers' Compensation Act

6. Appropriate Act (Mark X)

INJURED WORKER

PLEASE READ CAREFULLY - Submit this form to the Rehabilitation Counselor assigned to your case by OWCP. Complete items 7

thru 9, typing, or printing clearly with a ball point pen; then sign your name legibly in item 10. Next have an official at your facility certify

your statement by completing items 11 thru 13.

7. Weekly Training Schedule Monday Tuesday Wednesday Thursday Friday Saturday Sunday Other

8. Days Absent From Program (Month, Day, Year) 9. Reason For Absence(s)

10. INJURED WORKER: I certify that I participated in my rehabilitation program, as prescribed by the Office of Workers'

Compensation Programs, and hereby request a maintenance payment for the above period.

Signature Date Signed

11. Name 12. Title

13. FACILITY OFFICIAL: I certify that the above statement in item 8 is true.

Signature Date Signed

14. REMARKS:

15. Amount Approved 16. District Office No.

FACILITY

OFFICIAL

OWCP REHABILITATION SPECIALIST

OR REHABILITATION COUNSELOR

17. OWCP REHABILITATION SPECIALIST or REHABILITATION COUNSELOR:

I recommend the amount approved be paid to the injured worker.

Signature Date Signed

Print Name

REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES

IF YOU HAVE A DISABILITY, FEDERAL LAW GIVES YOU THE RIGHT TO RECEIVE HELP FROM THE OWCP IN THE FORM OF

COMMUNICATION ASSISTANCE, ACCOMMODATION(S) AND/OR MODIFICATION(S) TO AID YOU IN THE OWCP CLAIMS PROCESS. FOR

EXAMPLE, WE WILL PROVIDE YOU WITH COPIES OF DOCUMENTS IN ALTERNATE FORMATS, COMMUNICATION SERVICES SUCH AS

SIGN LANGUAGE INTERPRETATION, OR OTHER KINDS OF ADJUSTMENTS OR CHANGES TO ACCOMMODATE YOUR DISABILITY.

PLEASE CONTACT OUR OFFICE OR YOUR OWCP CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE.

OWCP-17 (Rev. 02-19)

FOR OWCP USE ONLY

Previous editions usable

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