Supervisor s Instruction by lnwh62f


									MCXL-MO                                                                           6 June 2006

MEMORANDUM FOR All Supervisors of Appropriated Fund (AF) Civilian Employees

SUBJECT Letter of Instruction Regarding Civilian Work Related Injuries

1. When AF civilian personnel incur a work related injury the supervisor should issue a DD 689
(sick slip) for the injured employee to carry to the Urgent Care Facility for the employee to be
seen for medical evaluation. If more than 24 hours has passed since the injury occurred the
Occupational Health Office must be contacted for an appointment or for any follow-up care
appointments. The Urgent Care physician will send a copy of the DD 689 back to the supervisor
with any work restrictions specified. It is important for the supervisor to include the employees’
directorate and contact telephone number on the DD 689.

2. A form CA-16 should be issued in cases in which the employee indicates he/she will be seen
by a civilian health care provider. To be valid, a form CA-16 must give the full name and
address of the physician/medical facility the employee elects to have authorized to provide
service and must be signed and dated by the supervisor. The name and address of the
employees’ place of employment should be listed as Civilian Personnel Advisory Center, (Attn:
Carla Laird), 5450 Strom Thurmond Blvd, Rm 229, Fort Jackson, SC 29207-5500. In cases of
traumatic injury where emergency treatment is necessary, the supervisor may give oral
authorization for treatment and a form CA-16 issue to the authorized medical provider within 48
hours thereafter. Except for emergency cases, form CA-16 may not be issued for past medical
care. For questionable claims, item 6b box 2 should be checked to indicate its doubtful nature to
the physician.

3. The form CA-1, Notice of Traumatic Injury must be filed with the Injury Compensation
Program Specialist (ICS) whether or not the employee seeks medical treatment. If an employee
suffers a work-related disease or illness the employee must complete form CA-2, Notice of
Occupational Disease (Note: form CA-16 may not be issued it these cases). Claims should be
submitted manually or through the DoD EDI (Electronic Data Interchange) system
(, then click on EDI-Supervisor’s View). If filing the
claim manually, the supervisor must be carried by the supervisor to the ICPA located in the
CPAC (Strom Thurmond Bldg., Rm 229) within 2 days of receipt from the injured employee.
This must be done whether or not you feel the claim should be approved. If you have specific
information which casts doubt on the claims validity, you may challenge it and supply
supporting information, but you must still forward the claim timely. Failure to do so can result
in a fine, imprisonment, or both, under 20 CFR 10.23 (c).

4. POC for this memorandum is the undersigned at 4-4561 or the Injury Compensation Program
Administrator in the CPAC, Mrs. Carla Laird at 4-6426.

                                             Martha L. Alsup, RN
                                             Chief, Occupational Health Section

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