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This form is provided for purpose of obtaining a medical duty status report for iw. In addition to completing items 17 through 39, the supervisor is responsible for obtaining the witness statement in item 16 and for filling in the proper codes in shaded boxes a, b, and c on the front of the form. It is split into two sections: Enter the owcp file number in the top right corner. You can also download it, export it or print it out. Web as the time the form is received, complete the receipt of notice of injury and give it to the employee. Sign it in a few clicks. Fill in the address of the employing agency and the appropriate owcp district office in the spaces below. Send ca17 via email, link, or fax. Share your form with others.
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Web as the time the form is received, complete the receipt of notice of injury and give it to the employee. It is split into two sections: Complete side a and refer the form to the physician to complete side b. Enter the owcp file number in the top right corner.
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