Form OWCP-17 Rehabilitation Maintenance Certificate

Form OWCP-17 or the "Rehabilitation Maintenance Certificate" is a form issued by the U.S. Department of Labor.

Download a fillable PDF version of the Form OWCP-17 down below or find it on the U.S. Department of Labor Forms website.

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U.S. Department of Labor
Rehabilitation Maintenance Certificate
Office of Workers' Compensation Programs
Print
Reset
IMPORTANT: No monies or benefits can be paid under this program unless this report is completed and filed as requested by
OMB No.1240-0012
law (5 U.S.C. 8111;33 U.S.C. 901 as extended and amended). The information collected will be handled and stored in
Expires: 11-30-2018
compliance with the Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 130.
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation),
accommodations and/or modifications, please contact OWCP. See additional guidance below for REQUESTS FOR
ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.
1. Name of Injured Worker (First, Middle Initial, Last)
2. OWCP No.
3. Complete Mailing Address (No., Street, City, State, ZIP Code)
Address Line 1
Address Line 2
City
State
ZIP
4. Maintenance Payment Per Week
5. Maintenance Pay Period (Month, Day, Year)
6. Appropriate Act (Mark X)
From
Thru
Federal Employees' Compensation Act
$
Longshore and Harbor Workers' Compensation Act
PLEASE READ CAREFULLY - Submit this form to the Rehabilitation Counselor assigned to your case by OWCP. Complete items 7
thru 9, typing, or printing clearly with a ball point pen; then sign your name legibly in item 10. Next have an official at your facility certify
your statement by completing items 11 thru 13.
7. Weekly Training Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other
8. Days Absent From Program (Month, Day, Year)
9. Reason For Absence(s)
10. INJURED WORKER: I certify that I participated in my rehabilitation program, as prescribed by the Office of Workers'
Compensation Programs, and hereby request a maintenance payment for the above period.
Date Signed
Signature
11. Name
12. Title
13. FACILITY OFFICIAL: I certify that the above statement in item 8 is true.
Date Signed
Signature
14. REMARKS:
15. Amount Approved
16. District Office No.
17. OWCP REHABILITATION SPECIALIST or REHABILITATION COUNSELOR:
I recommend the amount approved be paid to the injured worker.
Date Signed
Signature
FOR OWCP USE ONLY
REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES
IF YOU HAVE A DISABILITY, FEDERAL LAW GIVES YOU THE RIGHT TO RECEIVE HELP FROM THE OWCP IN THE FORM OF
COMMUNICATION ASSISTANCE, ACCOMMODATION(S) AND/OR MODIFICATION(S) TO AID YOU IN THE OWCP CLAIMS PROCESS. FOR
EXAMPLE, WE WILL PROVIDE YOU WITH COPIES OF DOCUMENTS IN ALTERNATE FORMATS, COMMUNICATION SERVICES SUCH AS
SIGN LANGUAGE INTERPRETATION, OR OTHER KINDS OF ADJUSTMENTS OR CHANGES TO ACCOMMODATE YOUR DISABILITY.
PLEASE CONTACT OUR OFFICE OR YOUR OWCP CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE.
Previous editions usable
OWCP-17 (Rev. 09-15)
U.S. Department of Labor
Rehabilitation Maintenance Certificate
Office of Workers' Compensation Programs
Print
Reset
IMPORTANT: No monies or benefits can be paid under this program unless this report is completed and filed as requested by
OMB No.1240-0012
law (5 U.S.C. 8111;33 U.S.C. 901 as extended and amended). The information collected will be handled and stored in
Expires: 11-30-2018
compliance with the Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 130.
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation),
accommodations and/or modifications, please contact OWCP. See additional guidance below for REQUESTS FOR
ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.
1. Name of Injured Worker (First, Middle Initial, Last)
2. OWCP No.
3. Complete Mailing Address (No., Street, City, State, ZIP Code)
Address Line 1
Address Line 2
City
State
ZIP
4. Maintenance Payment Per Week
5. Maintenance Pay Period (Month, Day, Year)
6. Appropriate Act (Mark X)
From
Thru
Federal Employees' Compensation Act
$
Longshore and Harbor Workers' Compensation Act
PLEASE READ CAREFULLY - Submit this form to the Rehabilitation Counselor assigned to your case by OWCP. Complete items 7
thru 9, typing, or printing clearly with a ball point pen; then sign your name legibly in item 10. Next have an official at your facility certify
your statement by completing items 11 thru 13.
7. Weekly Training Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other
8. Days Absent From Program (Month, Day, Year)
9. Reason For Absence(s)
10. INJURED WORKER: I certify that I participated in my rehabilitation program, as prescribed by the Office of Workers'
Compensation Programs, and hereby request a maintenance payment for the above period.
Date Signed
Signature
11. Name
12. Title
13. FACILITY OFFICIAL: I certify that the above statement in item 8 is true.
Date Signed
Signature
14. REMARKS:
15. Amount Approved
16. District Office No.
17. OWCP REHABILITATION SPECIALIST or REHABILITATION COUNSELOR:
I recommend the amount approved be paid to the injured worker.
Date Signed
Signature
FOR OWCP USE ONLY
REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES
IF YOU HAVE A DISABILITY, FEDERAL LAW GIVES YOU THE RIGHT TO RECEIVE HELP FROM THE OWCP IN THE FORM OF
COMMUNICATION ASSISTANCE, ACCOMMODATION(S) AND/OR MODIFICATION(S) TO AID YOU IN THE OWCP CLAIMS PROCESS. FOR
EXAMPLE, WE WILL PROVIDE YOU WITH COPIES OF DOCUMENTS IN ALTERNATE FORMATS, COMMUNICATION SERVICES SUCH AS
SIGN LANGUAGE INTERPRETATION, OR OTHER KINDS OF ADJUSTMENTS OR CHANGES TO ACCOMMODATE YOUR DISABILITY.
PLEASE CONTACT OUR OFFICE OR YOUR OWCP CLAIMS EXAMINER TO ASK ABOUT THIS ASSISTANCE.
Previous editions usable
OWCP-17 (Rev. 09-15)
Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5. U.S.C. 552a), you are hereby notified that (1) the Federal Employees Compensation
Act (FECA) as amended and extended (5 U.S.C. 8101, et seq.) and the Longshore and Harbor Workers' Compensation Act (LHWCA), as amended
and extended (33 USC 901 et seq.) are administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, which
receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to
determine eligibility for and the amount of benefits payable under the FECA and LHWCA and may be verified through computer matches or other
appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify
statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to entitlement to benefits or
other relevant matters. (4) Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain information
relevant to a decision under the FECA and LHWCA to determine whether benefits are being paid properly, including whether prohibited dual
payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the
FECA and LHWCA and/or the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the
payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays
a valid OMB control number. Public reporting burden for this collection of information estimated to be 10 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. The obligation to respond to this collection is required to obtain a benefit (5 U.S.C. 8101 and 33 U.S.C. 901). Send comments regarding
the burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers'
Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB
Control Number 1240-0012. Note: please do not send the completed form to this office.
Previous editions usable
OWCP-17 Page 2 (Rev. 09-15)

Download Form OWCP-17 Rehabilitation Maintenance Certificate

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