Attachment 2 CA-1
Employee completes areas highlighted in orange
Supervisor completes areas highlighted in blue
Bear
Smokey
555-55-5555
08/09/1964
4
909-555-5555
Employee’s home address and phone
1234 Conifer Lane
Priest River
1
X
Physical address where injury occurred
02/10/2009
800
02/11/2009
Forestry Technician
While cutting line, I slipped on a piece of wood and fell to the ground, hitting a large
rock with right knee. Be Specific about injury
GS-0462
210
0860
Bruised right knee, possible dislocated knee cap
Supervisor completes a, b & c
X
Smokey Bear
I saw Smokey fall down and hit his knee on a rock while he was cutting line, and
I went to help him up because he was in a lot of pain
Woodsy Owl
2/11/2009
Witness statement may be addressed on a separate
piece of paper
Bear, Smokey
555-55-5555
Write last name, first name and social
security # at the top
FS WC completes
USDA Forest Service ASC-HRM
3900 Masthead NE, Annex WC
Albuquerque, NM 87109
FS WC completes
Employee’s duty station location
X
X
0900
1800
X
X
X
X
X
X
X
02/10/2009
2/11/200
9
N/A
2/11/2009
Supervisor should contact FS WC with any concerns about claim
2/10/200
9
1000
2/20/2009
0900
X
Leave blank if employee hasn’t returned to
work. If no time lost, enter date of injury or
enter date employee returned to work
If yes, statement may be addressed in a separate sheet of paper
Complete this section for third party
involvement
02/10/2009
Complete treating physician information if
available
If no, statement may be addressed in a separated sheet of paper
Statement may be addressed in a separated sheet of paper
Gifford Pinchot
Provide a phone number you can be reached at
Please check the
applicable box