INTERIM INSTRUCTION - COMPENSATION FOR INJURY OR DEATH

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP80-00679A000100010111-3
• Release Decision: RIPPUB
• Original Classification: C
• Document Page Count: 21
• Document Creation Date: November 17, 2016
• Document Release Date: July 12, 2000
• Sequence Number: 111
• Publication Date: February 27, 1953
• Content Type: REGULATION

Approved Rix Ridease 29,9,1?4FIA-RDIZ$0-0110579A000100010111-3
rity Informatien
27 7ebruary 1953
191')41
?.::?Ift3OITT2, DIREGnit 1:61-10RANDUM. LU. 12 -53
Mb.E4,,IT3 Mterim Instruction Compensation I 3V tnju.ry or Death
-_ Th o.t hd interim instruction on compensation for injury
or deaill incurred the performance of duty i3 issued pending publi-
tion of an Agency egulation on this subject, This is the first a
e aeries of such ins ctions to be published in the next few 'weeks:,
Lernal Illcedures of 'ersonnel Office will conform to thoso
ralaiVirszle-47.?triarAittratriairiii?iri Agency-
14.ZiniaiiirtlirritUa;a Ian -supersede the present CIA
formation copies of th instruction will be distributed to
interested offices of the Age y, Comments or suggestions of
offices are invited in order t they may be considered in the
yAratton of the Regniation? Offices lying information copies
Ja being asked to forward their comments to the Personnel Office, attng
-)ch an6 Planning Staffl by 23 March
INFORMATION
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;:famv-ity Information
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* or= ion
:irvauN L!:ortucTioN
compons4tion for Injuly or Death
1? PolV7
4,o
PhTSONNEL
'ZAployees of? the Central Intelligence Agency are entitled to compensation
be fit under the Federal Smployees, Compensation Act (Public Law 267,
64th Oongross) as amended and/or the Central Intelligence Agency Act of
1949 (Plblit't Law 110, alet Congress) as amended,: These benefits include
comoensAtion for dinabi3ity and death, and medical care for employees who
aultr urie in the perftxmance of their duties.
JellnitioAs
the Performance of Duty,'
'*IY1 the performance of dutyo, as used in this Instruction, means that
th lndividualqs injury is directly attributable to or materially
aguravated by his ;lurk and is not the result of the employee 4s will-
ful Alsconduct, intoxication, or intention to bring about the injury-
or dcAth of himelf or another,,
%WU ,14
.or the purposes of this Instruction, the term "injury' includes, in
addition to injury by accident, any disease promimately caused by the
emplwment of the individual.
CoIrora.m.
a? Federal Zmplorses0 Compensation Act
(1) The provisions of the Federal Employee& Compensation Act apply
to employees of the Central Intelligence Agency Who are citizens
revidents of the United States or a territory of the United
(2'; 4mployees of the Centrrd Inl,,Aligente Agency who are neither
,Atiem. nor idents of the United States nor a territoi, of
tbe United :Antes will becompensated substantially in ao-
e3o.idance. with the benefit provisions of local wor)omenos compensa-
tion lams and r8gulatims. as i.f,ecognized by the United States
34u.r.NstofFiakIplOYeZ*0 C.4j.TISPetraP9. :AIMS a
en ]. teliigenoe Agenny Act of 1949
&mpllyees otherwise eligible for benefits under the Federal Compensation
whoso claims may not be submitted to the Bureau of Employeee
INFORMATION
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COVFIDENTIAL
Security Information
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., * PERS ONNE L
nnnnennation for security reasons will be granted these benefits
Irenr the authority contained in Section 10 of ths Central Intelligence
Annnny Act of 19490
Ronncnnibilities
d
The ?tesistant Director ("Personnel) is responsible for the administra-
t.lon of this program? for prescribing necessary procedures and for
eoordinating activities of other offices responsible for the
perfamance of related functions. HO, or his designees, Will determine
hether clains are to be processed rrder the provisions of the Federal
EnIiloyees Compensation. Act or the Ccntral Intelligence Agency Act
midifl adndnistrativeljr approve or disapprove those processed under
tnn latter Act?
1110 attioe Chief concerned, the Chiefs Medical Staff, the General
Ooannei and the Security Officers CIA g are responsible for providing
431kil recommendations connerning medica/ legal or security issues
involved in c?etermining the method of processing or the compensability
nn individual claire as are requested by the Assistant Director
Lnrnoune1)9 or his designee.
nnnnnfieoinr aliCia.18 are responsible for Tarnishing such documentas,
'.:ondis and 'information as may be requested,
ZnpAoyaos who claim benefits are responsible for complying with the -
pronndural requirements set forth below and for fulfilling such other
rusts for information and exnminations as may be nsoessary0
Benefits
Gamva),.
Inro-mation end advice as to benefits in specific eases will be
pnnnidp.d by the Personnel Office upon request., The general benefits
tn nhich employees REV be entitled are listed in Appendix Pi, Brief-
"if they inclrde the following
(0 :myment for medical services awl supplies. regardless of
,lhenher the injury has resulted in loss of worktin?,
Lore of income benefits based upon time lost from work and upon
ie nature of disability or disfigurement,
t.3. Allowance for the services of an attendant for totally disabled
pc.Y. sons,
INFORMATION
GOWEIDENTIAL
Seourity Information
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7
?
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Ap p rovedZ9 r Nap leaszecinlv
INTERIM IASIfOCTIUU
AAARDa80101679A000100010111 -3
(4) Allovaneo for vocational rehabilitation of perms:mm.61y dieabled
KJonse
Deth benefits had on the employeeqs monthly pay and the
nmber and reletonphin of his dependents,
'6) alowance 4,o7 funeral expenses, under certain circumstance
TngYeerind
are not entAled to compensation for loss of pay for the
ti-tree days of dsability unless the period of (Usability
eiftx,:af-i
U. days OY is permanent.
o, Uocl,s .ick or Annual Leave
If 514p1oye so electss, sick and/Or annual leavn or leave without
pay' loay be utilized diatime the period of disability, In such cases,
owpwasation paylaits will become effective upon termination of leave,
fateTnative Zenefits
uho is entatled to compensation benefits und6r the Federal
ye3sA 'Compensation Act, as amended,,, or the QIA Act s ap-
7.0,-Lole may also qualify for other benefits, Por example, an
nuployee eligible tor compensation benefits may also be eligible
a Ote.iability annuity under the Civil Service Retirement Act, An
onployee who i3 eligi.b)(3 for alternativ benefits shell elnet uhizh
b:_nefits he will receive for the period the benefits aro
6, Treatment
a, T.4.1*ciA treatmmt of it employee inured in the performanue of duty
be avransoi by his supervisor as fol lovsg
Personnel stazionod in anshington will be referred to the Agency
cal
iAffice?
of a T, 3, field station outside Washington will be
Lurrac to tbe local CIA medical oCficers; if one is available,
4ftwim, it sscakity considerations permit they will be
,e-E?,cre(1, be the nearest U. So Crovernment medical fat:laity or
phoician designated by the Bureau of Employees ? Compensationo
If neither a local CIA medical officer nor a
1? S, Oevernment medical facilityngT a designated physician
(tCA be used, the Ghiof, Eedical 5tafft will be contacted for
tructions cr, in an emergency case treatment may be obtained
- 3
uoDIF Daraca.
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INTERT. INSTRUCTION FERSaINCL
A ratr.,my, ?
b, ADy injury incurred in the performance of duty which disables or is
likely to disable an employee will be reported by the supervisor of
the employee oencerned on Form. C. A. 29 Official Superiorcs Report
of' injury. (Sample copy of Form C. A. 2 is included in Appendix B.)
This fora will be prepared in duplicate awl forwarded to the
Personnel Office through appropriate administrative Channels. When
treatment has not been furnished by the Agency Vedical Office, the
8upervisor will arrange for completion of the Government Medical
Officers statement on the reverse side of Form Go 11?, 2, if ap-
olioable, unless security considerations preclude furnishing this
iniarnation.
c. dnation of disability of an injured employee will be reported
- by hie supervisor on Form C, A. 3 (upper portion))) Report of
Termination of Total or Partial Disebility? unless it has previously
been reported on Form C. A. 22 Official Superioros Report of Injury.
FOTM Oc, A. 3 will be prepared in duplicate and forwarded to the
Personnel Office through appropriate administrative channels.
L Death of an employee as a result of an injury incurred in the
oarformnnce of duty will be promptly reported by the employee 's
supervisor on Form C. A. 3 (lour portion), Report of Death, Form
C, A, 3 will be prepared in duplicate and forwarded to the Personnel
Office through appropriate admdnistrative channels,
8, (Zee
An employee injured in the performance of duty will make claim for
reembureement or paymont of the cost of medical services and supplies
snd for comperusation for loss of pay on Form C. A. 4, Claim for
c:omeeneation on Account of Datery. (Sample copy of Form C. A. Ii is
lnnluded in Appendix B.) Form C. A. 4 will be prepared in duplicate
within 60 days fraa the date of injury. Documents in support of the
zAJI*2,m, including afl itemised bills and receipts, travel orders and
Ciaj,148 for personal expeeditures by the individual, will accompany
Foam C, 1 The Attending Physicians Certificate on the reverse
ei4e of Form C. A. 4 will be obtained if security considerations
peznit. The oupervisor of the injured employee will complete the
Geetificate of Official Superior of Injured Employee on the reverse
LIAe of Form Co A. 40 Completed forms will be forwarded to the
'Versonnol Office through appropriate administrative channels.
Claim for compensation benefits by the survivor(e) of an employee who
dies as the resat of an injury incurred in the performance of duty
will be made on Form C,A. 59 Claim for Compensation on Account of
Denth, Form C. A. 5 will be submitted to the Personnel Office in
daolteato.
5
INFORMATION COVIDWIAL
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InrormatIon
TISTRUCnU,.4
PrAtS0qE),
Tiaim for reimbuksement of tmvel expense incident to swing
(see paxweOta 6 n and 6 d above) will be made at
tan&rti. Form Eb, /012 Voucher for- Per Diem and/or Reimbursement
If 3xpexsee Inci6bnt to Official Travel.) This claim will be edb-
Ala& 4,o the Personnel. Office through appropriate administrative
n_sptant ;AreiAor (Persormel) or his designee will review each
tc determine ahsther it is to be processed under the provisions
igaeicderal LI-ap-foyees. Compensation Act or the Central Intelligenco
vey Acto
Clams procestd under the 'federal Smployeeet Compensation Act
be foruar*W by the Personnel Office to the Bureau of
oyee8' Competsvtion for adjudication, on a classified or
-,ApOassified basie OB the situation warrants.
ZI=Ams procesold under the Central Intelligence Agency Act
::aY1 be adminiAtratively approved or disapprove4 by the
.734.,q,Astant Direotor (Persormel) or his deign.
Approved claims will be forwarded to the Finance Divibion
tor paymehlt.)
W Disapprowd claims will be returned to the claimant with
A mamorandum Acting the reasons for disapproval? A copy
of this mAntymiwill be forwarded to the Office Chief
concequkt,
6
GiAFIDENTIAL
INFORMATION ;eourlty information
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A1ENDIX A
COMMISATION BEIEMS
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NO,
NS NS
Can,NSATION BENEFITS
1? Nospital and medio41
eXpS/100
2, Travel o of
treatmapf6
?1, Ser. Ll.ceti or an
attendaff:,
C011ipenVA/OTE 07;'
1013
Auwente,d compsosa,ticn
or depen4ents
FunernibiUo
7, Death Bmefits
a. taidcw
b. UidcAg:,,T
ChilexA
02:11,Lan childmr,
e. Derterdent Pa_ n
t? Other dependents
plALIFICATIONS
I. approvod facilities used
nd procedures followed
If local facilities are not
svitAble or available
necamsary because employee
is so helpless as to require
constant attention
If desired. Ni take accrued
sick and annual leave
If ons or more dependents.
RAntionshipw Nife, Husband4
Unmarried child,
Dependent Parent
If death results from the
inju7,71
a. Until remarriage or death
b. Yr wheAly dependant upon
ulUe. (oTil romarriagN
6.ath or capdble of self-
support)
child marries, dies,
ox,. reaches 18
d. Same as 4i
AMOUNT
Varies with case
Varies with case
Not to exceed t75 Per
Month
646 2/3% of monthly
salary or schedule award
8 1/3% of month4 pay
(Limited to that part
oE monthly pay not in
excesa of 0420)
Disoretionary,,
Not to exceed 0400
ao 45%
b 45%
c. To widow 40%g and
15% for each child
not to exceed 75%
d. 35% for one child and
/5% for each adr
ditional child not
to exceed 75% divided
among such children
share and share alike
If one dependent and e.
ono not
If both are dependent
If one dependent
If more than one
If one wholly dependent
bat one or more only
partially dependent
(1) 25%
(2)
20% to each
f. (1) 25%
(2) 30% share alike
(3) 10% share alike
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EMPLOYEE'S NOTICE OF INJURY OR OCCUPATIONAL DISEASE
Federal Employees' Compensation Act
This notice should be submitted to the immediate superior by an injured civil employee of the Federal Government,
or by someone on his behalf, within 48 hours after the injury. Notice may be given either personally or by mail. It should
be retained by the official superior unless the injury causes disability for work beyond the day or shift when injury occurred,
or results in any charge against the Bureau for medical expense, when it should be forwarded to the U. S. DEPARTMENT
OF LABOR, Bureau of Employees' Compensation, together with the official superior's report of injury, Form C. A. 2. Before
compensation is paid, written claim on Form C. A. 4 must be submitted to the Bureau.
1. I hereby certify that I am employed as a
Date of this notice , 19
(Occupation)
at the
(Place of employment)
and on ,19 ,at m.
(Day of week) (Date) (Hour, a. m. or p. M.)
I was injured in the performance of my duties at
(Location where injury occurred)
2. Cause of injury
(Describe as best you can how and why injury occurred)
3. Nature of injury
(Name part of body affected?fractured left leg, bruised right thumb, etc.)
4. Names of witnesses to injury
5. If this notice was not given within 48 hours after the injury, explain reason for delay and state name
of person to whom notice was first given, and when
This injury was not caused by my willful misconduct, intention to bring about the injury or death of
myself or of another, nor by my intoxication, and I hereby make claim for compensation and medical
treatment to which I may be entitled by reason of the injury sustained by me.
Rev
ePt,1*
Name
Address
(Street and number)
Ve(State)
ld2F or Meban.,?9,9111,913/1,64;kgq1A-RDFIR.:PPV9A000104010111-a
Approved kigAtisme gentigtm, g gaggles ciitoutwpc 100010111-3
To be submitted to U. S. DEPARTMENT OF LABOR, BUREAU OF EMPLOYEES' COMPENSATION, Washington 25, D. C., as soon as practicable after any injury to
a civil employee of the United States sustained while in the performance of duty which causes any disability for work beyond the day or shift on which the injury occurred or
results in any charge against the Bureau for medical expense. This form should be accompanied by C. A. 1.1
Place of
employment
1. Department 2. Bureau or office
(War, Navy, etc.) (Engineer, Navigation, etc.)
3. Place of employment
4. Reporting office
(Arsenal, navy yard, etc.)
(City) (State)
(Location of reporting office or division headquarters)
5. Name of superintendent or foreman in charge when injury occurred
The injured
employee
6. Name of injured employee 7. Age _ 8. Sex 9. Race
(Give first name in full)
10, Home address
(Street and number) (City or town) (State)
11. Occupation and division 12, Was employee doing his regular
(Give both, as laborer, hull division; helper, machine shop, etc.)
work? If not, what work?
13. Total length of service with the Government as a civilian?
14. How long at present work in this establishment?
15. Dates of other injuries
and subsistence valued at $ per
16. Rate of pay on date of injury, $ per
and quarters valued at $ per
17. Employee begins work at m. 18. Regular day's work ends M.
(Hour, a. m. or p. m.) (Hour, a. in. or p. m.)
19. Hours worked per day 20. Days paid per week
21. Place where injury occurred
(Give exact location, as name or number of building and division, etc.)
22. Date of injury , 19 ; day of week ; hour of day m.
(a. m or p.m.)
23. Date employee stopped work , 19 ; day of week ; hour of day m.
(a. in. or p. m.)
24. Date employee's pay stopped , 19 ; day of week ; hour of day m.
(a, in. or p.m.)
25. Has employee returned to work?
(Give date and hour)
26. Will employee receive pay for any portion of above absence on account of:
(a) Annual leave
(Give exact dates)
(b) Sick leave
(Give exact dates)
(c) Any other reason
(Give exact dates)
27. Describe in full how injury occurred
28. State part of body injured and nature and extent of injury
29. Did injury cause loss of any member or part of member? If so, describe exactly
The injury
30. Was employee injured while in performance of duty? If not, or in doubt, give detailed statement
31. Was injury caused by:
(a) Willful misconduct of the employee? (b) Intention of employee to bring about injury or death
of himself or another? (c) Employee's intoxication?
(If any answers to these questions are made in the affirmative, the reporting officer should attach an additional statement giving the
reason for his conclusion)
32. Was written notice of injury given within 48 hours? If not, did immediate superior have actual
knowledge of injury?
(Answer to question 5, Form C. A. 1, must be complete if notice was not given within 48 hours)
3$. Names and addresses of witnesses to injury
(If disability will continue for more than one day, have statements of witnesses made on reverse side of this form)
34. Was injury caused by a third party other than a Government employee or agency? If so, has
employee been instructed in procedure under the Bureau's regulations?
(A detailed statement should be forwarded with this report)
35. Name and address of physician who first attended case
Medical 36. How soon after injury?
attendance 37. To what hospital sent? Location
38. Name and address of physician now attending case
Signed this day of ,19
at
(Signature of reporting officer)
(Title)
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STATEMENT OF WITNESSES
[The statement of witness should tell just what the witness saw personally, or, if he did not see the injury occur, just what he
knows about it and when and by whom the information was given him.]
Signed this _________ day of , 19
(Signature of witness)
Signed this day of , 19
(Signature of witness)
STATEMENT OF GOVERNMENT MEDICAL OFFICER OR PHYSICIAN WHO FIRST
EXAMINED CASE
I CERTIFY that was given first-aid treatment, or examined,
(Name of eiriplogec)
on , 19 , at in., and disabled for work. Probable length of
(Was or was not)
disability will be In my opinion disability due to injury
(Was or was not)
on ,19
Nature of injury as found on examination
Hospitalized Will return for further treatment
Discharged Other disposition
Remarks
Signed this day of
at
U. S. 00?1311Z01.2 PRINTINO 0111011 18-0027
(Signature of medical ojAcer)
(Title)
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CLAIM FOR COMPENSATION ON ACCOUNT OF INJURY
To be filed with the official superior, within 60 days after the injury causing disability for more than 3 days, for transmission to
the U. S. DEPARTMENT OF LABOR, BUREAII OF EMPLOYEES' COMPENSATION]
CLAIM MUST BE FILED WITHIN ONE YEAR AFTER INJURY
NOTICE: fment, knowing it to be false, shballbl:eviguilz of perjduriy and i shall be punished by a fine of not more than $2,000, or by imprisonment
Section 39 of the Compensation Act of September 7, 1916, provides that whoever makes, in any claim for compensation, any state-
or pot snore
an one year, or
fine
+ '? +
1. Name of injured employee 2. Age 3. Sex
[Give first name in full]
4. Mail address
[Street and number] [City or town] [State]
5. Married, single, widowed. 6. Race 7. Occupation and division
[Cross out two words]
8. Rate of pay when injured, $ per
(a) Were subsistence and quarters furnished by the United States?
were they received in addition to rate of pay?
(b) If So or [Answer "Yes" to one]
was their value deducted from pay?
(c) In either case, state value: Subsistence, $ per ; quarters, $ per
9. Time of injury
10. Disability for work began 1Date1
19_ m.
[Day of week] [Hour a. In. or p. an.]
, 19 m.
[Date] [Day of week] [Hour a. m. or p. an.]
11. First able to resume usual occupation 19 m.
[Date] [Day of week] [Hour a. In. or p. In.]
12. Period for which compensation is claimed. From to
13. Have you received any pay from the overnment during period of disability:
On account of annual or sick leave Dates , Total amount, $
Specify any other reason Dates , Total amount, $
14. Have you worked for anyone during the period of disability? If so, give name and address of
employer, dates worked, rate of pay, and total amount earned
15. Were you furnished subsistence or quarters (other than in hospital) during period of disability?
If so, give dates on which subsistence or quarters, or both, were furnished
16. If medical, surgical, or hospital service was furnished by private physicians or hospitals, state amount of
expense incurred, $ and submit an itemized bill for this service with an explanation of
reason for not using United States medical officers or hospitals, if available.
17. If transportation and other expenses necessary to enable you to secure proper medical and hospital treat-
ment were incurred by you, state amount of expense so incurred, $ If reimbursement is
claimed submit itemized receipted bill for such expenses.
[Give dates, places of travel, and amount paid; also any special expense necessary because you had to travel from your regular place of residence in
order to get proper medical treatment]
18. Place where injury occurred
[Give exact location, as name or number of building, and division, etc.]
19. Cause of injury
[State exactly how injury occurred]
20. Nature and extent of injury causing disability
21. Have you made claim against any person for damages on account of the injury described above?
If you have received any money in payment of damages, state amount, $
22. (a) Have you ever been in the military or naval service? If so, state approximate periods
served and in what organization
(b) Have you ever applied for compensation or pension on account of such service? If so,
give claim number and office where filed
(c) Are you now receiving compensation or pension, retainer, or retirement pay on account of such
service? If so, give details
23. Have you applied for, or received, annuity under Civil Service Retirement Act?
24. Dates of oth.er injuries, if any, on account of which you have made claims for compensation
I HEREBY make claim for compensation on account of the injury described above, which was sustained by
me while in the performance of my duty for the United States, said injury not being due to willful miscon-
duct on my part or to my intention to bring about the injury or death of myself or another, or to my intoxica-
tion. I have been disabled on account of this injury and have not refused or failed to perform any work I was
able to do during the period for which compensation is claimed and every statement set forth above in support
of my claim is true to the best of my knowledge and belief.
Signed this day of , 19 , at
[Signature of claimant]
Subscribed and sworn to before me this _ day of ?,
cA,f o)7tcial administering oath]
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[In and for]
Revised May 24, 1950
16--11485-2
[Title]
ATTENDING PHYSICIAN'S CERTIFICATE AND MEDICAL REPORT OF DISABILITY
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I CERTIFY that has been under my professional care from
[Name of injured employee]
to inclusive, for the effects of injuries sustained on
In my opinion, employee has been totally disabled for all work from to
and partially disabled for usual occupation from to
Patient was able to resume regular work
may be
was
Patient i. may be j able to resume light work
1. Dates of treatment visits: .(a) Office
(b) Home (o) Hospital
2. Nature of treatment provided for effects of injury
(a) Operation (b) Date performed
3. What further treatment is recommended?
Specify special services indicated, if any, such as: Consultation, hospitalization, orthopedic appliances, etc.
4. State what history of injury was given by employee
5. Describe the symptoms or physical findings for which treatment was given
(a) X-ray?laboratory?specialist's reports
6. State how your findings confirm your opinion that the disability was due to injury
7. Describe complicating and other concurrent diseases or disabilities present
8. Employee was confined (a) to his home from to ; (b) to bed from to
9. Are permanent effects of the injury probable? Describe in detail
10. If injury caused loss or dysfunction of a part, describe such loss in terms of function
?NOTE.?Ill all eases, wliere (a) the disability is protracted 30 days or more, or (b) where the medical relationship of the
condition to an alleged injury or to occupational conditions is not clear, forward a detailed medical report describing the onset
and clinical course of the condition, and discuss the medical aspects of the case which justify your opinion of the causal relation-
ship to an injury.
I am licensed to practice medicine and surgery in the State of
Signed this day of , 19
[Street and number]
[Signature of attendiCtg PhCian]
[City and Stats1
CERTIeATE OF OFFICIAL SUPERIOR OF INJURED EMPLOYEE
[Report of injury (Form C. A. 2) if not heretofore forwarded to the Bureau, should accompany this claim.]
any circumstances have arisen which alter the conclusions stated in the official report of injury (Form C. A. 2), or if
the offieial superior disagrees with any of the statements made in the claim for compensation, it is requested that a full
explanatory statement be made under 'Remarks."
1. If the injured employee is a piece worker or an irregular worker, what were his gross earnings during the month immediately
preceding the injury?' "$ ; actual dates on which he worked
[For example, if the employee was injured on the 7th of February, his gross earnings should be given for January 7 to February 6, inclusive]
2. Has employee' resumed work? If so, give date and hour
3. Has employee been paid for any portion of the absence for which compensation is claimed? If so, state inclusive
dates
4. Remarks ,
.. .
I HEREBY CERT/PY that the person who executed the foregoing claim for compensation was injured while in the performance
f is day for the United States. An official reportof this injury on Form C. A. 2 has been made, and all statements made in
report are true to the best of my knowledge and belief.
Signed this day of
at
I:VT-Yr? nimaita'pRikrdrta
? 19
[Signature of oecial superior]
'-"[iritte]
Approved F.,g,r Release 2000/08/16 7CIA-RDF19-00679A000100010111-3
Nme
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Approved For R1160a102000/08/16 : CIA-RDP80-0(09400100010111-3
11.??1,111. C
LITT QV FOrklii
Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3
1
Approved For RelikiEhit00/08/16 : CIA-RDP80-00VA4100010111-3 - -
FO= U541 IN REPOE2ING ?1JJhW., I kCN CLAIlt,? AND aLLUG AITEALS
Listed 'oelow are the forma regittred in injury and deatii cases un4or the
United States '.,4)nployees' Compensation Act of lylkg as amends:xi, This U
identifies tht title of each form and indicates by whom and 4104 eat form
should be submitted. Non-asterisked forms are zbtained from tha Itrsonacl
LtTice to indiaated bione asterisk are furnished direCt t by
the ;IWNX111; those indicated by two asteriske are furnishe6 ()At to lloapit4s
nndAystaianr,
Title
C.I ployee,
of Injury o: Ofl'-
upstioma
sem.,
A, 2
Ao 2
To uesubmitted--
,;mplor:17e4t! (or soneonetii ithin 46 hours T)r, as 860r
after injury as ts ppacticab-L*,
Form filed etapllts
pervoimel folder :LA
1.r.4,u7 .n81410 nnt
to VAL* :)44rilaer,
in nim behal11-
Usficial lja ii;mpioyoer, al
Report of Ipjnry
perior,t ,J,xpivyv.18
f!eport of :411jury.
(:o ooler recur-
rence of disability
origirxza
jrisn)
tuparvialw
C,44,a00
.),amer 84 :iorm Z. L. 14 IZ
injury results it cjy
for worh !-Aeyona the Ji4
abiZt of oczarranooi, or YA6ht
result in zzy &4i czkirm
atalnst th%i compensation ,!)4d.,
Llraerliateljhu r jjved
employec.% ible
from the 3ai4 ittjur,r, ',"orms
shou.74 be PIthrtild
and thzuld aont,t2f.t1.refialvt-t
.fat p ttz Ino.aryo
getv datrz.t 414.4,r,t1. ati
tttopptld. 44A1pOrt ;1i7 tpe art
ibeetwo ccmered bv let's
shotld niso be 71:
disAbiliV hoe
? the mpgrt ism.t4.,:.4 th.e Oste
aDd hoar of ret.;.,:rt.,, t) duty
shluld be Mown ethrwie
rt, an Fr m Cc, tt?, 3
should be made whcn the em-
ployes returns t,o work cr
disability' ceases.
Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3
!APAR?
?
Form
10 3
3
Approved For Rea41102000/08/16 : CIA-RDP80-0
PAPP
R...41.1013
By--
To be submitted--
.11111111.111.11C11.011,39.6.300WWISAMTIMIMMIIIMINF.M.41112.16.??6111... ?11.1.16101.0...
Report of Termination
of Total cv ?artial
Disability,
(pper korti?.4
4oport ,7.T Leath
fo).Jor .'ortion)
C. 1, 4 Clip for Compensation
on Account of injury
off, c
A,
r r.;
?4.
Application for Aug-
mented Compeneation
for Disability
V Application for ..ard
Z'r DisflguroaantG
trLalsti for CoPpowatton
O ?Acoutit a D,6atti.
Ao 51. 'Application for 19alanae
of 5chedu1p
is ?rom Cauees
4tAher than tht,3 Injurl?,
Olvim for Continu-
am of Cottpamatiort
,kccaunt of div.
c, 1. incard
C. A 0 11 t C.mttairdre
Resnma
)tight s to Componee
tion Berieftte.
Lmplo-
0100010111-3
-171 tt,71
?
,
.0.0......PAAAPPOMMIONWITAANIMARMIONAWOOPOORRINA,
Vben--
1111.10.000.10.114.03011111.11.1?MOORM:
Immediately upim r::tat1.4%,,sclEt,
return to mor. et4r 416 -
ability* unloe puch roprrt
hoe been made ?.v.s
or othorides,,
:,",sigmatiEttioficlAl.,,,,,, Immediately's tet be 11'.=
comported by rorort an
Form Co A. 2s itouch form
has not provienslean elea-
mitted.
Employee (or alwtona act- Athin L da,r after pay' stone,
ing .1.r.1 his behalf), but not 1,:eter Chan 60 dwp
atter injury,, %Yplanation
must accompany, clan if sub-
mitted later than 6D days
after injury,,
Lmployee (or so, one aigt- Accoripaniav C? 4 uten
in in his behalf). depondmney bits are
claimed.
.;raployee (or someonm
acting In hie behalf),,
15exteficiAry
Ileneficiary
Accompanies V, A, h in ca2es
of diefignrement rf races
heads or neck,
As coon se poerible after
deaths but not later than
I year,
?
I iliont etter death
and not Ilter t'.!) I
plo7.1e (or nomeone act- 'Al5 lenst
inu in hip ",71Ralf
17.' rtlyth,
Approved For Release 2000/08/1e: 8IA-RDP80-00679A000100010111-3
r " Approved For Releafs2000/08/16 : CIA-RDP80-07V 0100010111-3
To be eUbmitted
Title
When--
12 Glaim of Widow or
Olidoeer for Continued
Compeneation on )\c-
eount of Death.
13 0,1eim of Guardian
ter. itinor Children for
Continued Compensa-
eionon Account of
Death,
. A. /3A Claim for Continued
Cempensation on Ac.
Count of Death by
Lependent Phyeically
incapeble of 43e1f-
Lepportb
14 Reqeest of Dependent
Ulrents or Grendpere
tants for Additional
Compensation on Ac-
count of Death,
A,
Co A. 16
Request for Treatment
of Injure Under the
United States Eeploye
eeel Compensation Act.
(Request for treatment
bY no:I-designated Ohy-
vician will be issued
ip letter form.)
ldow or widewer or guard- On the ].at dey of eanuare
ian on behalf of such and July of each year uhtle
beneficiary if mentally the compensatien continuee,
incompetent
Legal nor natural guard- StiMe
ian or guardian ex officio
cm behalf of a minor ar
eentelly incapacitated
beneficiary other than
wido widowers? par
-
ante, or grandparents.,
Inaapacitated benefici-
axies other than widows,
widowers, parents., or
grandparente who are
not minors and have no
guardian.
as Form C,
Same as or C, A. 12.
Dependent parents or'Same as Form Co A. 12.
aeandparents.
Employnege supervisor
or Medical Officer.
17 Reqeest for Treatment Eeployeeqe supervisor
of Injery Under the oe Medical Officer.
United States Employee&
Cempensation Ant When Catoo
of Injury i i Doubt
(Same Ls Form C. A. 16.)
Attending Pleimicianes Attending phyeician
Report.
A, 20
a:lechery Report of
Immediately after the ac-
cident, if praetioeble.
Authorization for emergency
treatment may be in before
issuance of this forme, pro-
vided it is issued within 48
hours thereafter.
Immediately in order that it
can be forwarded to proper
office for neceseary action.
As eoon as possible,
Boapital, di5pensary9 When patient is discharged.
lkury Case., or designated physician.
- 3 -
Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3
a. I
Approved For Relkidili300/08/16 : cIA-RDP80700VA100010111-3
,,,a,x,ea.....a.......afgataciashAmtexemostAmern.toorarommit."....altwalv,awomaAr...aneamoroserlowaravo.....
?orm
By--
,tedNtal.1011M.,..grk....10.P1161.10.1(,..Vat 4irrn.0.011*.t111.**
t
vo Ao
0 33
heport of Auvria
itequest (by Nreau)
for 1& LLr'
ow,
c AL/42 fik ii Rsaating
to Representatives
of Deceased Be,nro-
fftbiaries
A,
Affidavit of
Unclert,saker
oyee'4 s Claim
f'vr Continuance of
Compemation cii
,Lccount e
:thilit llhen Case
Is Carried en Auto
List of Phyntic?iAll.-3
and Rosp:Itriruth Appmmi
by Bureau WhIch Axv,
Available to Injured
E.OploSte&-3?
II0 83 Inployee a Notice of
Comensation Payment,
by 3ur40,,u.
A? 86 Uficial superiorqs
Wotice of Comensa-
tion Payment by
AL
rnpioye Usim for
-Contirmance of Co6.
To be submitted--
Claimant and attending
physician
Dareau
when--
As soon as possible.
As deemed nectog.,,,ea:rj
;Ay person liavfaag know- As -soon as posSible after
ledge of the funeral and burial of deceased asiplqiee0
burial expenses other .
than the undertaker or a
nerber of his establish-
Pittnto (This form is used
when there it no adminis-
tration of tho deceased
ervloyee,s estate in
claiming burial allow-
ance or compensation
due the deceased employte
at the time of his death.)
Undertaking establishMent? As soon as possible after
burial of deceased employeeL
Emplowe In lieu of C. A. 8
Bwmau
auJeau,
qlloyte
In lieu of C. h. 8 uhan
nedicel evidence is not
vensation
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Awroved For Relkiphil300/08/16 : CIA-RDP80-00VA
Wet,rwtvoursaaaprovemocoM,^ -124, vola4.1.6%.
Fora
' Title
.eastwown.
;11 777771, 1,7
100010111-3
To be eUbmittedee
0 -a...x.4W.. mp. Amlarasavaitunaks *pa 094111tliteIDIK.............1....11.10111.11?1110411.10...,..4110.11110
A. 96 4mp1oye 48 Affidavit
Disclosing Leerningre
if any., During
arability,
eCel '.gent of CieSmelt
oeS-69
Peelle Voucher for
e'erscks',4es axel Supplies
of Houpitale atxt
Standard Voucher fcei Per
Form 1012e Adam sndior Reim-
,)seraert,
-,:ymses Incident
0ffici22 Travel?
e:itandard >ubljc Veructer for
;Porsu 1?034. a? 7 Chaea eat!
elrvicee Other Than
eeesoenl,
?
'
eeplicatioe for
eeview
Zmployee (pax L.
dieabled)
Claimant '(or attorney
authorized to at in his
behalf).
Injured employee, physi-
cians, nurses, hospitals,
and any person or firm
furnishing supplies or
services for medical and
allied expenses. If
signature of employee
cannot be obtainad?
a concise explanation
of the reason. nuet be
included
Injured employee
1
4.0.11,...M.0.110MMOUNtiewrt,14.
As equested by Buteau.
Upon approval of Claireeee
attorney by the fillreinic,
When employee is dieeharged
from treatment? unless treate
mat. extends for more then
30 dare, in which event it
shall be submitted at the
end of each 30-dey period.
When travel ie completed,
or if repeated tripe are
made, as often aa convenient
in accordance with Standard
United Statet Government
Travel Regulation.
Undertaking establishment As soon as poseible 'after
or person or firm furnish-burial of deceased employee.,
ing services in connection '
with funeral or burial
expensea of deceaeed
enployeee
itreor affected by Bureaues Within 90 daye after
decision. iseuence of final deciaion by
Bureau. Tine limit may be
waived by Board in extenua-
ting cases, provided
application is filed within
1;e4er.
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