INSTRUCTIONS FOR COMPLETING FORM CA-2
Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental statement
to the form. in addition to the information requested on the form, both the employee and the supervisor are required to submit additional
evidence as described below. If this evidence is not submitted along with the form, the responsible party should explain the reason for the
delay and state when the additional evidence will be submitted.
Complete items 1 through 18 and submit the form to the employee's supervisor along with the statement and medical reports described below.
Be sure to obtain the Receipt of Notice of Disease or Illness completed by the supervisor at the time the form is submitted.
2) Medical report
a) Dates of examination or treatment.
1) Employee's statement
In a separate narrative statement attached to the form, the
employee must submit the following information:
a) A detailed history of the disease or illness from the date it
b) History given to the physician by the employee.
c) Detailed description of the physician's findings.
d) Results of x-rays, laboratory tests, etc.
started.
b) Complete details of the conditions of employment which are
believed to be responsible for the disease or illness.
c) A description of specific exposures to substances or stress-
e) Diagnosis.
ful conditions causing the disease or illness, including
locations where exposure or stress occurred, as well as
the number of hours per day and days per week of such
exposure or stress.
f) Clinical course of treatment.
g) Physician's opinion as to whether the disease or illness
was caused or aggravated by the employment, along with
an explanation of the basis for this opinion. (Medical
reports that do not explain the basis for the physician's
opinion are given very little weight in adjudicating the
claim.)
d) Identification of the part of the body affected. (If disability
is due to a heart condition, give complete details of all
activities for one week prior to the attack with particular
attention to the final 24 hours of such period.)
e) A statement as to whether the employee ever suffered a
similar condition. if so, provide full details of onset,
history, and medical care received, along with names and
addresses of physicians rendering treatment.
3) Wage loss
If you have lost wages or used leave for this illness, Form
CA-7 should also be submitted.
At the time the form is received, complete the Receipt of Notice of Disease or Illness and give it to the employee. In addition to completing items
19 through 34, the supervisor is responsible for filling in the proper codes in shaded boxes a, b, and c on the front of the form. If medical expense
or lost time is incurred or expected, the completed form must be sent to OWCP within ten working days after it is received. In a separate narrative
statement attached to the form, the supervisor must:
c) Attach a record of the employee's absence from work caused
a) Describe in detail the work performed by the employee.
by any similar disease or illness. Have the employee state the
reason for each absence.
Identify fumes, chemicals, or other irritants or situations
that the employee was exposed to which allegedly caused
the condition. State the nature, extent, and duration of the
exposure, including hours per days and days per week,
requested above.
d) Attach statements from each co-worker who has first-hand
knowledge about the employee's condition and its cause. (The
co-workers should state how such knowledge was obtained.)
b) Attach copies of all medical reports (including x-ray reports
and laboratory data) on file for the employee.
e) Review and comment on the accuracy of the employee's state-
ment requested above.
The supervisor should also submit any other information or evidence pertinent to the merits of this claim.
24. First date medical care received
The date of the first visit to the physician listed in item 23.
14. Nature of the disease or illness
Give a complete description of the disease or illness. Specify
the left or right side if applicable (e.g., rash on left leg; carpal
tunnel syndrome, right wrist).
19. Agency name and address of reporting office
32. Employee's Retirement Coverage.
The name and address of the off ice to which correspondence
from OWCP should be sent (if applicable, the address of the
personnel or compensation office).
Indicate which retirement system the employee is covered
under.
33. Was the injury caused by third party?
23. Name and address of physician first providing
A third party is an individual or organization (other than the
injured employee or the Federal government) who is liable for
the disease. For instance, manufacturer of a chemical to which
an employee was exposed might be considered a third party if
improper instructions were given by the manufacturer for use of
the chemical.
medical care
The name and address of the physician who first provided
medical care for this injury. If initial care was given by a
nurse or other health professional (not a physician) in the
employing agency's health unit or clinic, indicate this on a
separate sheet of paper.
OWCP Agency Code
This is a four digit (or four digit two letter) code used by OWCP
to identify the employing agency. The proper code may be obtained
from your personnel or compensation office, or by contacting OWCP.
Box a (Occupational Code), Box b. (Type Code), Box c
(Source Code), OSHA Site Code
The Occupational Safety and Health Administration (OSHA)
requires all employing agencies to complete these items when
reporting an injury. The proper codes may be found in OSHA
Booklet 2014, Record Keeping and Reporting Guidelines.
Form CA-2
• U.S. GPO: 2001480-204/59062
Rev.Jan.1997
Employee (or person acting on the Employee's behalf)
Item Explanation: Some of the items on the form which may require further clarification are explained below.
Supervisor (Or appropriate official in the employing agency)
Employing Agency - Required Codes
