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- Begin by entering your personal information in Section 1, including your name, address, city, state, postal code, and phone number.
- In Section 2, provide details about your employment if applicable. Include your job title and employer's name and address.
- If you have legal representation, fill out Section 3 with your attorney's information. Ensure they sign if they are covering any fees.
- In Section 4, specify which court fees you are requesting an exemption for. Refer to the provided informational sheets for guidance.
- Section 5 requires you to explain why you need a fee waiver. Mark all applicable options regarding your income and financial situation.
- Complete Sections 7 through 11 with detailed financial information about your income, expenses, and assets as required.
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When to fill out a CA-1?
For traumatic injuries, file Form CA-1 within 30 days following the injury, and for occupational disease claims, file Form CA-2. Once you complete your portion of the claim form, it will be forwarded to your supervisor who will complete the supervisors portion before forwarding the form for review.
What must the first report of injury contain?
Contents of the First Report of Injury Employee Information: This section includes details about the injured employee, such as their name, address, social security number, date of birth, job title, department, and contact information. It may also include information about the employees supervisor or manager.
What is the difference between CA-1 and CA-2?
CA-1 - Federal Employees Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. Use for traumatic injury - employee was hurt because of a single event or within one workday. CA-2 - Notice of Occupational Disease and Claim for Compensation.
What is a DWC 3 wage statement in Texas?
The rate of compensation to which an employee is entitled is based upon his or her average weekly wage as defined in the law. The information in the Employers Statement of Wage Earnings Form (DWC-3) is necessary to properly calculate the employees average weekly wage.
What is a CA-1 form used for?
The CA-1 form should be used if you have sustained a traumatic injury on the job. A Traumatic Injury is a wound or other condition of the body caused by external force, including stress or strain.
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Who fills out the CA-1?
As the supervisor, it is your responsibility to complete this form. However, if you have any reason to believe that the information provided by the employee is not correct, there are sections of the CA-1 where additional information should be provided: Section 28: Was the employee injured in the performance of duty?
What does CA-1 stand for?
In the first year (CA-1 clinical anesthesia) residents are immediately introduced to the operating room under the instruction of an experienced anesthesiologist and senior residents who assists the trainee in becoming acclimated to the new environment.
Related links
The employer is required to file an Employers First Report of Injury or Illness. [DWC FORM-001 Rev. 10/05] with the injured workers insurance carrier, and the.Read more
Describe in detail how and why the injury, illness, or death occurred (Include the events leading up to the injury or illness, state the actual injury,Read more
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