Madison Location Accident/Illness Reporting Instructions
Listed below are the documents that need to be completed and returned to Terri Gureno (firstname.lastname@example.org) within 24 hours of the Incident/Accident.
Form CA-16 Authorization for Examination And/Or Treatment - authorizes an injured employee to obtain immediate examination and/or treatment from a physician chosen by the employee for an on-the-job injury. Forms are available from Terri Gureno, Julie Grogan, or from SHEM stations within each building.
Form CA-20 Attending Physician’s Report – If you decide to see a medical professional 48 hours or more after the incident, you will need to take the CA-20 form and give to the attending physician to complete. This form along with the appointment bill is then sent to the Worker’s Compensation Specialist in Beltsville.
Form CA-1 Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation – Please complete all boxes 1-15. Do not complete shaded areas. Witness (If there is a witness) Complete bottom section 16. Supervisor completes all of the 2nd page. I will complete OWCP Agency Code and OSHA Site Code. If a question is not applicable to you or the situation enter N/A in the boxes. All boxes must be filled in or the form will be rejected at Headquarter’s.
Form CA-2 Notice of Occupational Disease and Claim for Compensation
Form CA-2A Notice of Recurrence
Accident Report Form
OSHA Forms 300, 300A, 301 Instructions
OSHA Forms 300, 300A, 301 - Log of Work-Related Injuries and Illness
160.0M - Safety, Health, and Environmental Management Program P&P
Basic Program Elements for Federal Employees OSHA
Executive Order 12196 – Occupational Safety and Health Programs for Federal Employees