Other Form CA-17

2025 Printable Template

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Form last updated: 03/2024. Please verify this is the current version before use.

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01

Fill out your form

Our user-friendly editor helps you quickly enter personal & business details in the CA-17 template.

02

Sign the form

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03

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How to fill out a CA-17 online?

Follow these steps to complete your CA-17 form online.

Step 01

Access the pre-loaded form in the PDF editor.

Step 02

Complete Side A with the employee's information and injury details.

Step 03

Fill in the usual work requirements and describe how the injury occurred.

Step 04

Have the treating physician complete Side B with their findings.

Step 05

Verify that all fields are filled out accurately.

Step 06

Download the completed form for submission.

Office of Workers' Compensation Programs (OWCP)

What is a CA-17 used for?

Form CA-17 is used to report an employee's work status following an injury. It helps assess the employee's ability to return to work and outlines any necessary work restrictions. This form provides important information to employers and the Office of Workers' Compensation Programs (OWCP) for managing workers' compensation claims.

Who needs to fill out a CA-17 form

The employee's supervisor and the treating physician are required to complete this form.

What is the purpose of Form CA-17?

It documents an employee's work status and injury details to assist in workers' compensation claims.

Who completes each section of the form?

Side A is filled out by the supervisor, while Side B is completed by the treating physician.

When is Form CA-17 due?

The form should be submitted promptly after the physician completes it.

What should I do if I need a blank Form CA-17?

You can obtain a blank form from the Office of Workers' Compensation Programs (OWCP) website or your employing agency.

Where should the completed form be sent?

It should be sent to the Office of Workers' Compensation Programs (OWCP) and a copy retained by your employing agency.

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