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Ca-2a DOL-ESA Forms

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U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Notice of Recurrence
OMB No. 1215-0167
Expires: 05-31-2011
Employee: Complete Part A below.
Employing Agency (Supervisor or Compensation Specialist): Complete Part B.
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.
Part A - Employee
3. OWCP file number for
original injury
2. Social Security Number
1. Name of employee (Last, First, Middle)
6. Home telephone
5. Sex
4. Date of birth
Mo. Day Yr.
FemaleMale
8. Dependents
Wife, Husband
Children under 18 years
Other
10. Name and Address of Employing Agency at time of recurrence,
9. Name and Address of Employing Agency
at time of original injury (number, street, city, state, ZIP code)
if other than shown in 9. If you are no longer employed with the
Federal Government, complete Part C also.
13. Date and Hour stopped
11. Date and Hour 12. Date and Hour 15. Date and Hour14. Date and Hour pay stopped
after recurrence
returned to work
work after recurrence
(mo., day, year)
of recurrenceof original injury
(mo., day, year)
(mo., day, year)
(mo., day, year) (mo., day, year)
18. Name and address of treating physician
17. Date of first medical treatment
following recurrence
(mo., day, year)
Medical Treatment Only
Time Loss From Work
19. After returning to work following the original injury, were you in any way limited in performing your usual
duties? (If so, explain. Also state how long these limitations continued.)
Yes
No
20. Describe your condition since you returned to work, including the nature and frequency of all medical treatment received.
21. Describe how and when the recurrence happened. Explain why you believe your current condition is related to the original injury.
22. Describe all injuries and illnesses which you suffered between the date you returned to work after the original injury, and the date of
recurrence. Arrange for the submission of all relevant medical records.
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain
compensation as provided by the Federal Employees' Compensation Act (FECA), or who knowingly accepts compensation to
which that person is not entitled, is subject to civil or administrative remedies as well as felony criminal prosecution and may,
under appropriate criminal provisions, be punished by a fine or imprisonment or both.
I hereby claim medical treatment if needed, and up to 45 days Continuation of Pay if disabled for work.
I hereby authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any
desired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative).
This authorization also permits any official representative of the Office to examine and to copy any records concerning me.
I certify, under penalty of law, that the information provided on this form is true and correct to the best of my knowledge.
23. Signature of employee
24. Date (mo., day, year)
Form CA-2a
Rev. Sept. 1996
( )
7. Home mailing address (include city, state, and ZIP code)
Reset
Print
Part B - Federal Employing Agency
25. Name and address of reporting office (include city, state, and ZIP Code)
OWCP Agency Code
ZIP Code
OSHA Site Code
27. Date of first return to FULL- TIME REGULAR
duty following original injury
Mo. Day Yr.
29. Regular
28. Regular
Sun.
Tues.
Thurs.
work
work
a.m. a.m.
days
hours
To: :
Fri.
Mon.
Wed.
Sat.
p.m.
p.m.
31. Date 32. Date
30. Date
Mo. Day Yr. Mo. Day Yr.
Mo. Day Yr.
a.m.
of
of
stopped
work after
Time :
recurrence
injury
p.m.
recurrence
34. Dates COP
Mo. Day Yr.
35. Date33. Date
paid for
returned
pay stopped
From
Mo. Day Yr.
Mo. Day Yr.
recurrence
to work
after
a.m.
after
recurrence
To
Time :
p.m.
recurrence
37. At the time of the recurrence did your
36. Did the employee receive medical care at an agency facility
Yes
Yes
agency authorize medical treatment
on Form CA-16?
due to the recurrence?
If so, please attach all relevant medical records.
No
No
38. After the original injury, did you make any accommodations or adjustments in the employee's regular duties due to injury-related limitation?
No If so, provide full details.
Yes
39. After return to work, did the employee sustain any other injury or illness which affected performance of his or her duties? If so,
provide full details.
40. Please review the statements made by the employee in Part A of this form and provide any relevant comments and additional information.
A supervisor or compensation specialist who knowingly certifies to any false statement, misrepresentation, concealment
of fact, etc., in respect to this claim may also be subject to appropriate felony criminal prosecution.
42. Title41. Signature of Supervisor or Compensation
Specialist (at time of recurrence)
43. Work phone
44. Date
(mo., day, year)
26. Employee's duty station (street address and ZIP Code)
ZIP Code
( )
From: :
Part C - Employee
(To be completed by the employee if not employed with the Federal Government at the time of the claimed recurrence)
1. For all jobs held since you left the job held when the initial injury occurred, list the full name and address of your employers, and the
inclusive dates of employment. Include any self-employment.
2. For all jobs listed in item 1 above, provide your job title, nature of duties performed, number of hours worked per week and rate of pay.
3. Describe all educational and/or vocational training received since your original injury. Include any licenses or certificates earned.
4. What was your rate of pay if you stopped work due to this recurrence?
per
$
Yes
5. Do you claim compensation for lost wages?
No
If so, for what period?
through
No
Yes
6. Have you received any pay during the period claimed?
If so, how much and from what source?
information is required to obtain and retain benefits in order to
ensure the timely filing of a notice of recurrence of disability and claim for benefits
under the Federal Employees' Compensation Act (FECA). The information will be used to initiate and assist in the adjudication of the claim and
failure to
provide the information may prevent or delay claim processing. Additional disclosures of this information may be to: third parties in
litigation; employing
agencies; various individuals and organizations providing related medical rehabilitation and other services; insurance
plans which may have
paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the
GAO and IRS) as
appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.
7. Signature of Employee
8. Date (mo., day, year)
• U.S. GPO: 2000-467-602/39549
.
NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995,
as amended. The authority for requesting the following information is Section 8101, et seq., Title 5 to the U.S. Code. Furnishing the requested
INSTRUCTIONS FOR COMPLETING FORM CA-2a
NOTICE OF RECURRENCE
DEFINITION OF RECURRENCE
A Recurrence of the Medical Condition is the documented need for additional medical treatment after release from treatment for the
work-related injury. Continuing treatment for the original condition is not considered a recurrence.
A Recurrence of Disability is a work stoppage caused by:
• A spontaneous return of the symptoms of a previous injury or occupational disease without intervening cause;
• A return or increase of disability due to a consequential injury (defined as one which occurs due to weakness or impairment caused by a work-related
injury); or
• Withdrawal of a specific light duty assignment when the employee cannot perform the full duties of the regular position. This withdrawal
must have occurred for reasons other than misconduct or non-performance of job duties.
IF A NEW INJURY OR EXPOSURE TO THE CAUSE OF AN OCCUPATIONAL ILLNESS OCCURS, AND DISABILITY OR THE NEED
FOR MEDICAL CARE RESULTS, A NEW FORM CA-1 OR CA-2 SHOULD BE FILED. This is true even if the now incident involves the
same part of the body as previously affected.
INSTRUCTIONS FOR EMPLOYEE
• Review the definition of "recurrence" given above. If you believe that you have sustained a recurrence, complete Part A of this form.
Attach a separate sheet of paper if needed to provide full details.
• If you worked for the Federal Government at the time of the recurrence, submit Form CA-2a to your employing agency. If you no longer
work for the Federal Government, complete Parts A and C of this form and submit all materials directly to the Office of Workers'
Compensation Programs (OWCP).
• If you are claiming a recurrence of disability for an occupational illness, or if all 45 days of continuation of pay (COP) have been used,
you may claim wage loss on Form CA-7. The OWCP will pay compensation if the claim is approved.
• Arrange for your attending physician to submit a detailed medical report. The report should include: dates of examination and treatment;
history as given by you; findings; results of x-ray and laboratory tests; diagnosis; course of treatment; and the treatment plan. The
physician must also provide an opinion, with medical reasons, regarding causal relationship between your condition and
the original Injury. Finally, the physician should describe your ability to perform your regular duties. If you are disabled for your
regular work, the physician should identify the dates of disability and provide work tolerance limitations.
• If other physicians treated you after you returned to work following the original injury, obtain similar medical reports from each of them.
INSTRUCTIONS FOR EMPLOYING AGENCY
• After the employee has completed Part A, promptly complete Part B and submit the form to OWCP, unless: the claimant is still receiving
continuation of pay (COP); the recurrence is for medical care only and the claim is still open; or the claimant is currently requesting
neither wage-loss compensation nor payment of medical expenses. In these instances, file the form in the Employee Medical
Folder.
• If COP is being paid, obtain medical evidence using Form CA-17, "Duty Status Report", as often as circumstances indicate.
• For a recurrence less than 90 days after the employee's return to work following the original injury, you may authorize required
medical care using Form CA-16. For a recurrence more than 90 days after the employee's return to work, OWCP must authorize further
medical care.
• For recurrences of disability which continue after the 45 days of COP have expired or which involve occupational illness, instruct
the employee to file Form CA-7.
Public Burden Statement
Completion of this collection of information is estimated to vary from 15 to 45 minutes per response with an average of 30 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. If you have any comments regarding the burden estimate or any other aspect to
this collection of information, including suggestions for reducing this burden, send them to the Office of Workers' Compensation Programs,
U.S. Department of Labor, Room S-3229, 200 Constitution Avenue, N.W., Washington, DC 20210.
DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE.
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Completed 3 July 2020

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