Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
November 17, 2016
Document Release Date: 
July 12, 2000
Sequence Number: 
Case Number: 
Publication Date: 
February 27, 1953
Content Type: 
PDF icon CIA-RDP80-00679A000100010111-3.pdf1.71 MB
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 25X1A 25X1A VaFTD Tat, ;:famv-ity Information Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 Approved Rot kVleaseg IA-RDIZSO-61079A000100010111-3 * 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 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 COVFIDENTIAL Security Information Approvedvi.prlildlea%e 20 ;euriy Lthornha fliTnAIPI IWnRUCTIO ylaRDP480314679A000100010111-3 ., * 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 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 7 ? . , 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. INIAOPTIsYVAIIIE3c04 Release 24300/08/11e1a1tElP80-00679A000100010111 -3 25X1A Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 Approved For Re4reaswed200g4tA". rAt Fi84-04619,1460100010111-3 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 Approved For Release 200raget:tztrAntiMlb-00679A000100010111-3 Approved For Raloa1602000/08/46 261A1RDP80-094679M60100010111-3 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 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 Approved For RielOaft#2000/08/16 : CIA-RDP80-044,7954000100010111-3 A1ENDIX A COMMISATION BEIEMS Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 Approved ForRelease2000/08/16 : CIA-RDP80-00679A000100010111-3 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 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 ApprovepTgr lease 2000/08/16 : CIA-RDE80- / aPortit SAWLE 79A000100010111-3 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 Approved For Reiggseq000/08/16 : CIA4RDP80-00U9AQ80100010111-3 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) Revised .141-a.y 24, Approved FrirRelease 2000/08/1rtatIA-RDP80-00679A000100010111-3 Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 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) ApprovedrEir Release 2000/08/16 : CIA-RD*0410t79A000100010111-3 I. Approved For,aelease 2000/08/16: CIA-RQ,p80190679A000100010111-3 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 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] Rproved For Release 2000/08/16: CIA-RDP80-di5riri ? [In and for] Revised May 24, 1950 16--11485-2 [Title] ATTENDING PHYSICIAN'S CERTIFICATE AND MEDICAL REPORT OF DISABILITY Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111-3 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 ????????? 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. 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 Approved i-or Release 2000/08/16 : li!-RDP80-00679PAPOOP40010111-3 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. Approved For Release 2000/08/16 : CIA-RDP80-00679A000100010111 -3