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Ca 35 CA - (AFGE Local 1040 Members)

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U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Evidence Required in Support of a Claim
for Occupational Disease
All of the following information should be submitted with Form CA-2. Please return the checklist with your statements attached. Check off each
item as it is completed or let us know when we can expect the information. All material submitted should be legible and specific.
FROM EMPLOYEE
1. Give a detailed description of factors of
employment believed responsible for
condition. Be specific as to the duration
and nature of the factors: for instance
weights carried, distances walked, chemi-
cals used, or other relevant job actions.
2. Give the history of the condition from
first awareness of the problem. Include
description of all home treatment and
professional care as well as symptoms.
3. Describe any prior similar problem, with
8. Attach copies of the employee's:
dates of onset, history, medical care
received, and copies of the medical
records of your treatment.
a. SF-171, Application for Employment.
b. Position description with physical
requirements.
4. Attach or forward a medical report from
your physician to include the following
items:
c. Pertinent dispensary records.
a. Dates of examination and treatment.
d. Most recent SF-50, Notification of
Personnel Action.
b. History given by you.
c. Detailed description of findings.
d. Results of all diagnostic tests.
e. Diagnosis.
f. The clinical course of treatment
followed.
g. Doctor's opinion, with reasons for
such opinion, as to the relationship
between any condition you may now
have and the factors of employment
identified in Item no. 1 above.
Form CA-35A
Rev. Aug.1988
P
FROM EMPLOYING AGENCY
P
5. Review and comment on employee's
statement provided in response to Item
no. 1.
6. If employee's job differs from official
description, describe exactly his/her
duties.
7. Give a day-by-day listing of leave and
leave without pay used due to this
condition.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'
Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or
aggravated the disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial
effort. The attached checklist is designed to help you. Form CA-2 ("Federal Employees' Notice of Occupational Disease and
Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be
given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off
each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation
Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your
Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information
directly to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post
card advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Manage-
ment (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for
the same period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your
statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR
PHYSICIAN IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed check-
lists to help you and the employee submit a claim in an organized and complete manner. The checklists will help the
claims examiner identity what information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to
mark and return with the completed package. The second checklist is for the employee to take to the physician.
In addition to describing the evidence required from the employee, the checklists describe the information to be submitted
by the employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions
on the CA-2 to forward them to OWCP within ten working days. Statements and documents required from the agency
should be submitted with the CA-2 whenever possible. Please use the checklist to note what information from the
employing agency is enclosed, unavailable or pending. If pending, please give the anticipated mailing date. Agency
comments, statements and documentation are essential for the examiner to get a well rounded picture of the
employment conditions.
We appreciate your cooperation in this effort.
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Evidence Required in Support of a
Claim for Work-Related Hearing Loss
IF YOU ARE FILING A CLAIM FOR HEARING LOSS, THIS CHECKLIST DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR
EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2. Please return the checklist with your
statements attached. Check off each item as it is completed or let us know when we can expect the information. All material submitted
should be legible and specific.
FROM EMPLOYEE
1. List your employment history by em-
ployer, job title, and inclusive dates.
Include non-Federal employment and
military service.
10. Describe all work-related exposure to
hazardous noise, including:
2. For each job title, describe source of
a. Locations of job sites.
noise, number of hours of exposure per
day, and use of any safety devices to
protect against noise exposure. State
when safety devices were provided.
b. Nature of exposure to noise
(machinery, etc.).
c. Decibel and frequency level (noise
survey report) for each job site.
d. Period of exposure, hours per day,
days per week.
e. Type of ear protection provided.
Attach copies of the employee's:
a. SF-171, Application for Employment.
b. Job sheet and employment record.
c. All medical examinations pertaining
7. State whether a claim for workers,
to hearing or ear problems, including
preemployment examination and all
audiograms.
compensation benefits for this or any
other condition affecting ears or hearing
was ever filed. If so, give date of claim,
name and address where filed, and
benefits received.
12. If the employee is no longer exposed to
hazardous noise, give date of last
exposure and the payrate in effect on
that date.
Form CA-35B
Rev. Aug. 1988
11.
P
P
FROM EMPLOYING AGENCY
Review and comment on the employee's
statement in response to questions 1-5.
9.
3. Give history of any previous ear or hearing
problems.
4. Describe any hobbies which involve
exposure to loud noise.
5. If you are no longer exposed to hazardous
noise at work, give the date you were last
exposed.
6. If you have been examined or treated by
a doctor for an ear or hearing problem,
provide a medical report and audiograms.
8. Give the date you first noticed your hearing
loss.
Give date you first related hearing loss to
employment, and reason why.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'
Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or
aggravated the disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial
effort. The attached checklist is designed to help you. Form CA-2 ("Federal Employees' Notice of Occupational Disease and
Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be
given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off
each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation
Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your
Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information
directly to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post
card advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Manage-
ment (OPM) and workers' compensatiion benefits from OWCP. However, in most cases, you cannot receive both benefits for
the same period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your
statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN
IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed check-
lists to help you and the employee submit a claim in an organized and complete manner. The checklists will help the
claims examiner identify what information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2, Federal Employees Notice of Occupational Disease and Claim for Comeprisation, and
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to
mark and return with the completed package. The second checklist is for the employee to take to the physician.
In addition to describing the evidence from the employee, the checklists describe the information to be submitted by the
employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the
CA-2 to forward them to OWCP within ten working days. Statements and documents required from the agency should be
submitted with the CA-2 whenever possible. Please use the checklist to note what information from the employing agency
is enclosed, unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements
and documentation are essential for the examiner to get a well rounded picture of the employment conditions.
We appreciate your cooperation in this effort.
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Evidence Required in Support of A
Claim for Asbestos-Related Illness
If you are filing a claim based on exposure to asbestos. Use this checklist to identify the information needed from you and your em-
ploying agency. All of the following information should be submitted with Form CA-2. Please return the checklist with your statements attached.
Check off each item as it is completed or let us know when we can expect the information. All material submitted should be legible and specific.
10. Provide exposure data, including air sample surveys or
2. For each job title, describe the work you performed, the
statements of the type of asbestos exposure, frequency,
degree and duration for each job held. Air sample
results should be reported in units of fiber/cc time
weighted average. Also report concentrations of other
pollutants and chemicals (see attached questionnaire).
type of asbestos material used, locations where exposure
occurred, period of exposure, number of hours per day
and days per week exposed, and the types and frequency
of safety precautions (mask, respirator, etc.) used (see
attached questionnaire).
11. Give the date employee was last exposed to asbestos
at work. If the employee was removed from exposure,
give the circumstances.
12. Attach copies of the employee's:
a. SF-1 71, Application for Employment.
b. Position description with physical requirements
for last job hold.
6. Submit a report from your physician, including chest x-ray
report, history, physical findings, diagnosis, opinion as to
the relationship of the condition to employment, and course
of treatment.
c. Job shoot and employment record.
d. Pertinent dispensary records.
e. Most recent SF-50, Notification of Personnel
Action.
f. Laboratory test results and chest x-ray reports
on file.
13. Describe safety regulations and protective devices in
use by employee, with period and frequency of use.
Form CA-35C
Oct. 1987
P
P
FROM EMPLOYEE
1. List your employment history by employer, job title, and
inclusive dates. Include non-Federal employment and
military service (see attached questionnaire.)
FROM EMPLOYING AGENCY
Review and comment on the accuracy of the employee's
description of work performed and exposure to asbestos
and other substances.
9.
3. Describe any exposure you have had to other toxic sub-
stances. If none, state "None".
4. Describe any breathing or lung problems you have had in the
past and treatment received (see attached questionnaire).
5. Give your smoking history to include amount per day, and
years (dates) you have smoked (see attached question-
naire).
7. Give the date you first consulted a physician regarding res-
piratory or asbestos-related disease.
8. Submit reports of examination, treatment or hospitalization
for any previous similar condition or pulmonary problem.
PART A TO BE COMPLETED BY CLAIMANT
In order to determine if you are eligible for benefits, please provide the following information using your best estimates. If you run out of space, use
a separate piece of paper and attach it to this form. Submit the form to your current (or last) employing agency. If the facility is no longer active,
submit the statement to OWCP.
I. Employment History: Please include all employers, both Federal and non-Federal, your job titles, the work you performed, and the period
you held each job. (Include military service).
II. Exposure History: Please describe all exposure to asbestos and other toxic materials in your employment. Include period of employment,
type of exposure, number of hours exposed per workday and description of safety precautions used while working.
a. Asbestos: For "type of exposure" indicate whether exposure was heavy, medium or light:
Heavy - Visible airborne asbestos particles were evident.
Medium - Asbestos dust was visible on floors and work surfaces.
Light - No dust visible, but asbestos was in use.
b. Toxic Chemicals/Dust
(PLEASE CONTINUE ON REVERSE SIDE)
1.
Employer (Agency)
Job Title
Work Performed
Period
Fed. Civil Service? (Yes/No)
1 .
2.
3.
4.
5.
6.
7.
8.
Period
Type of Exposure (H, M, L)
Exposure Hrs/Day
Safety Precautions Used
1 .
2.
3.
4.
5.
Period
Material Exposed to:
Exposure Hrs/Day
Safety Precautions Used
2.
3.
4.
5.
Notice to Employees Filing Claim for Occupational Disease
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal
Employees' Compensation Act. You must provide factual and medical evidence to establish that conditions of employment
caused or aggravated the disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial
effort. The attached checklist is designed to help you. Form CA-2 ("Federal Employee's Notice of Occupational Disease and
Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be
given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off
each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation
Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your
agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information directly
to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post
card advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel
Management (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits
for the same period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your
statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN
IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
Notice to Compensation Specialists and Supervisors
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists
to help you and the employee submit a claim in an organized and complete manner. The checklists will help the claims
examiner identify what information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and
2. Two copies of the checklist describing evidence required-in support of the claim. One checklist is for the employee to mark
and return with the complete package. The second checklist is for the employee to take to the physician.
In addition to describing the evidence required from the employee, the checklists describe the information to be submitted by the
employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2
to forward them to OWCP within ten working days. Statements and documents required from the agency should be submitted
with the CA-2 whenever possible. Please use the checklist to note what information from the employing agency is enclosed,
unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements and documentation
are essential for the examiner to get a well rounded picture of the employment conditions.
We appreciate your cooperation in this effort.
Ill. Medical History: Describe your medical history and include any treatment for heart, lung and other major health problems.
IV. Smoking History: Describe your smoking history, including dates you smoked, amount of material smoked per day, and type of material
smoked.
PART B TO BE COMPLETED BY EMPLOYING AGENCY
Using the categories shown below, please complete the chart at the bottom of the page with reference to each Federal job hold by this employee.
a. Nature of Exposure:
Primary - Normal duties required actual manipulation of asbestos and/or asbestos-related products and generated dust.
Secondary - Normal duties regularly involved work alongside others primarily exposed or in confined spaces.
Intermittent - Normal duties irregularly involved entry into locations where asbestos and/or asbestos products were manipulated.
Environmental - Normal duties were performed at a location where asbestos was used but the individual had no normal exposure in excess
of ambient levels.
b. Degree of Exposure:
Heavy - Asbestos dust was usually visible in the air.
Medium - Asbestos dust was generally visible on work surfaces but did not cloud the air.
Light - Asbestos was used in work area but was generally not visible (although detectable).
Ambient - Asbestos levels did not exceed normal levels In the air outside of work spaces.
c. Frequency of Exposure:
Hours per day.
Period
Asbestos Exposure
Other Chemical or Dust Exposure
Job Title
Fiber/cc
From
Frequency
To
Material
Frequency
Nature
Nature Degree
Degree
*U.S. Government Printing Office: 1989-229-460/99190
Have you ever had:
Yes
No
If Yes, explain
Dates
1. Heart Problems?
2. Lung Problems?
3. Other Major
Problems?
Have you ever smoked:
Yes
No
If Yes, amount
No. of years
Date stopped
Dates
1. Cigarettes?
2. Pipe?
3. Cigars?
1.
2.
3.
4.
5.
6.
7.
8.
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Evidence Required in Support of a Claim
for Work-Related Coronary/Vascular Condition
IF YOU ARE FILING A CLAIM FOR CORONARY OR VASCULAR CONDITIONS (for example: heart attack, stroke, hypertension). THIS CHECKLIST
DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR EMPLOYING AGENCY. All of the following information should be submitted
with Form CA-2. Please return the checklist with your statements attached. Check off each item as it is completed or let us know when we
can expect the information. All material submitted should be legible and specific.
FROM EMPLOYEE
1. Give a detailed description of the factors
of your employment you believe respon-
sible for your condition. Identify dates,
periods, events, people involved, etc.
7. Describe in detail the duties of the
employee and the manner in which the
duties were performed. If the work was
different or more stressful than that per-
formed by other employees, this should
be explained.
2. If you are claiming compensation for a
heart attack or stroke, provide a specific
account of your activities on and off duty
for one week prior to the attack, with
emphasis on the twenty-four hours imme-
diately preceding the attack.
8. Document any personnel actions descri-
ed in the employee's statement, such as
changes in assignment, grievances filed by
the employee, and other adverse person-
nel actions.
3. If you have a prior history of heart pro-
blems, provide a description of your con-
dition and copies of medical records of
treatment.
4.
Give your smoking history to include
amounts and years (dates) you smoked.
5. Provide a medical report from your
physician which includes:
a. Dates of examination and treatment.
11. Attach copies of the employee's:
b. History given by you.
a. SF-171, Application for Employment.
c. Family history and other risk factors.
d. Detailed description of findings.
e. Copies of all diagnostic test results.
f. Diagnosis.
b. Position description with physical
requirements.
c. Preemployment medical examination.
d. All other pertinent medical reports
available.
g. The clinical course of treatment
followed.
e. Most recent SF-50, Notification of
Personnel Action.
Doctor's opinion, with reasons for
such opinion, as to the relationship
between any condition you may now
have and the factors of employment
identified in Item no. 1 above.
h.
Form CA-35D
Rev. Aug. 1988
P
P
FROM EMPLOYING AGENCY
6. Review and comment on the employee's
statements in response to questions 1-5.
9. Give the number of hours worked per
day, days per week and the extent of
overtime duty worked.
10. Provide a day-by-day listing of leave and
leave without pay used due to this condi-
tion.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'
Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or
aggravated the disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial
effort. The attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and
Claim for Compensation''), your statements in response to the checklist, and a report from your treating physician should all be
given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off
each item as it is completed to let us know when we can expect the information. Your supervisor and the Compensation
Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your
Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information
directly to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post
card advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Manage-
ment (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for
the same period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your
statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR
PHYSICIAN IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed check-
lists to help you and the employee submit a claim in an organized and complete manner. The checklists will help the
claims examiner identify what information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to
mark and return with the completed package. The second checklist is for the employee to take to the physician.
In addition to describing the evidence required from the employee, the checklists describe the information to be submitted
by the employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions
on the CA-2 to forward them to OWCP within ten working days. Statements and documents required from the agency
should be submitted with the CA-2 whenever possible. Please use the checklist to note what information from the
employing agency is enclosed, unavailable or pending. If pending, please give the anticipated mailing date. Agency
comments, statements, and documentation are essential for the examiner to get a well rounded picture of the
employment conditions.
We appreciate your cooperation in this effort.
Evidence Required in Support of a Claim
for Work-Related Skin Disease
U.S. Department of Labor
Employment Standards Administration
Office of Workers Compensation Programs
IF YOU ARE FILING A CLAIM FOR A SKIN CONDITION, THIS CHECKLIST DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR
EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2. Please return the checklist with your
statements attached. Check off each item as it is completed or let us know when we can expect the information. All material submitted
should be legible and specific.
FROM EMPLOYING AGENCY
FROM EMPLOYEE
1. Give a detailed description of employ-
6. Review and comment on the employee's
ment factors you believe responsible for
your condition, to include:
statements provided in response to ques-
tions 1-5. Comment on the exposure
claimed, providing any available informa-
tion about the trade name and/or chemi-
a. Specific type of exposure.
cal content of the suspected irritants.
b. Frequency and duration of exposure.
7. Provide a day-by-day listing of leave and
leave without pay used due to this condi-
c. Protective equipment used to guard
against exposure.
tion.
8. Attach copies of the employee's:
2. Describe any exposure to skin irritants
outside the work environment, including
the type, duration and frequency of
exposure.
a. SF-171, Application for Employment.
b. Position description with physical re-
quirements.
c. Pertinent dispensary records.
d. Copies of all physical examinations on
file.
e. Most recent SF-50, Notification of
Personnel Action.
5. Attach or forward a medical report from
your current physician to include:
a. History of exposure.
b. Findings.
c. Diagnosis.
d. Details of treatment.
e. Explanation of the relationship
between the findings and exposure
history listed in Item no. 1 above.
f. Discussion of temporary vs. perma-
nent effect from work exposure.
g. Work restrictions caused by the
condition.
Form CA-35E
Rev. Aug. 1988
P
P
3. Describe any previous skin conditions
from the time they began through the
present.
4. Provide treatment records from any
physicians who have provided treatment
for any skin conditions.
Evidence Required in Support of a Claim
for Work-Related Pulmonary Illness
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
(not asbestosis)
IF YOU ARE FILING A CLAIM FOR PULMONARY CONDITION NOT RELATED TO EXPOSURE TO ASBESTOS, THIS CHECKLIST DESCRIBES THE
INFORMATION NEEDED FROM YOU AND YOUR EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2.
Please return the checklist with your statements attached. Check off each item as it is completed or let us know when we can expect the
information. All material submitted should be legible and specific.
FROM EMPLOYING AGENCY
FROM EMPLOYEE
1. Describe the work conditions which
6. Review and comment on employee's
caused or aggravated your pulmonary
condition; include types of irritants, dates
of exposure and hours per day. Describe
any safety measures taken.
statement provided in response to
questions 1-5. Give periods, degree
and nature of exposure. Explain safety
precautions. Give full details of any
tests which were made to determine
the concentration of irritants. Have
other employees been similarly
affected?
2.
Explain the development of the present
pulmonary condition and treatment from
its beginning.
7. Provide a day-by-day listing of leave
and leave without pay used due to this
condition.
3. Give your smoking history to include
amounts and years (dates) you smoked.
8. Attach copies of the employee's:
4. Give the history of previous pulmonary
conditions: include dates and nature of
illness, and treatment records from all
physicians and hospitals where you were
treated.
a. SF-171, Application for Employment.
b. Position description with physical
requirements.
5. Attach or forward a medical report
which includes the following items:
c.
Preemployment medical examination
and any other pertinent medical
records.
a. Dates of examination and treatment.
d. Most recent SF-50, Notification of
Personnel Action.
b. History given by you.
c. Detailed description of findings.
d. Results of all diagnostic tests.
e. Diagnosis.
f. The clinical course of treatment
followed.
g. Doctor's opinion, with reasons for
such opinion, as to the relationship
between any condition you may
have and the factors of employment
listed in Item no. 1.
Form CA-35F
Rev. Aug. 1988
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NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'
Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or
aggravated the disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial
effort. The attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and
Claim for Compensation''), your statements in response to the checklist, and a report from your treating physician should all be
given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off
each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation
Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your
Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information directly
to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post
card advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Manage-
ment (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for the
same period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your
statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN IS
REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists
to help you and the employee submit a claim in an organized and complete manner. The checklists will help the claims examiner
identify what information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2. Federal Employees Notice of Occupational Disease and Claim for Compensation, and
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to
mark and return with the completed package. The second checklist is for the employee to take to the physician.
In addition to describing the evidence from the employee, the checklists describe the information to be submitted to by the
employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2 to
forward them to OWCP within ten working days. Statements and documents required from the agency should be submitted with
the CA-2 whenever possible. Please use the checklist to note what information from the employing agency is enclosed,
unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements and documentation
are essential for the examiner to get a well rounded picture of the employment conditions.
We appreciate your cooperation in this effort.
Evidence Required in Support of a Claim
for Work-Related Psychiatric Illness
U.S. Department of Labor
Employment Standards Administration
Office of Workers Compensation Programs
IF YOU ARE FILING A CLAIM FOR A PSYCHIATRIC CONDITION, THIS CHECKLIST DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR
EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2. Please return the checklist with your
statements attached. Check off each item as it is completed or let us know when we can expect the information. All material submitted
should be legible and specific.
FROM EMPLOYING AGENCY
FROM EMPLOYEE
1. Give a detailed chronological description
7. Review and comment on the employee's
of particular employment factors which
you believe caused your condition. Please
identify dates, periods, events, people
involved, etc.
statements provided in response to
questions 1-5. Submit statements from
witnesses, if appropriate.
8. Provide a detailed statement describing
2.
Describe the progress and development
of the work-related condition from its
beginning.
the duties of the employee and the
manner in which the duties were
performed. If the work was different or
more stressful than that performed by
other employees, this should be
explained.
3. Have you previously suffered from this
or a similar condition? If so, give details
of symptoms, disability and treatment
records from all physicians and
hospitals where you were treated.
9. Document any personnel actions
described in the employee's statement,
such as changes in assignment,
grievances filed by the employee, and
other adverse personnel actions.
10. Give the number of hours worked per
day, days per week and the extent of
overtime duty worked.
11. Provide a day-by-day listing of leave
and leave without pay used due to this
condition.
12. Attach copies of the employee's:
a. SF-171, Application for Employment.
b. Position description with physical re-
quirements.
c. Preemployment medical examination.
d. All other pertinent medical reports
available.
e. Most recent SF-50, Notification of
Personnel Action.
Form CA-35G
Rev. Aug. 1988
P
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4.
Give a brief description of your personal
activities, hobbies, and any other em-
ployment.
5. Describe changes or other sources of
stress in your personal life occurring in the
same time frame.
6. Attach or forward a medical report as
described on the reverse.
MEDICAL REPORT FOR PSYCHIATRIC CLAIM
You should submit a medical report from your physician which includes:
a. History of onset of illness.
b. Social and family history.
c. Detailed description of your work situation and identification of the specific work factors contributing to your emotional or psychiatric
condition.
d. Review of any non-industrial stress situations.
e. Mental status examination, with pertinent findings.
f. Results of psychological and personality testing.
g. Diagnosis according to DSM III.
h. Clinical course of treatment followed.
i. Prognosis with estimate of when you will be able to return to work.
j. Physician's opinion, with reasons for such opinion, as to whether, how and which factors of your employment caused,
aggravated, precipitated, or accelerated your disability.
k. An assessment of your current condition, with specific details on how you can or cannot function in daily activities, including a
discussion of any limitations you may have in your ability to give or take supervision, cooperate with others, work under deadlines,
or any other pertinent factors which may effect your work capacity.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'
Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or aggravated the
disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial effort. The
attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and Claim for
Compensation''), your statements in response to the checklist, and a report from your treating physician should all be given to your agency
Compensation Specialist at the same time. Please return the checklist with your statements. Check off each item as it is completed or let us
know when we can expect the information. Your supervisor and the Compensation Specialist will compile the additional information
required and forward a complete and organized package to OWCP. If your Agency has no Compensation Specialist or other person
designated to forward information to OWCP, give the information directly to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post card
advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management (OPM)
and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for the same period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your statements
answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN IS REQUIRED. Reports
on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists to help you
and the employee submit a claim in an organized and complete manner. The checklists will help the claims examiner identify what
information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to mark and return
with the completed package. The second checklist is for the employee to take to the physician.
In addition, to describing the evidence required from the employee, the checklists describe the information to be submitted by the
employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2 to forward
them to OWCP within ten working days. Statements and documents required from the agency should be submitted with the CA-2 whenever
possible. Please use the checklist to note what information from the employing agency is enclosed, unavailable or pending. If pending,
please give the anticipated mailing date. Agency comments, statements and documentation are essential for the examiner to get a well
rounded picture of the employment conditions.
We appreciate your cooperation in this effort.
U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Evidence Required in Support of A Claim
for Work-Related Carpal Tunnel Syndrome
If you are claiming that your carpal tunnel or wrist problems are due to your job, use this checklist to identify the specific
All of the following information should be
information needed from you and your employing agency to make a decision on the claim.
submitted with Form CA-2. Please return the checklist with statements attached. Check off each item as it is completed or let us know when we
can expect the information. All material submitted should be legible and specific.
FROM EMPLOYEE
1. Prepare a statement giving the following information:
a. Provide an outline of your work history, including non-
Federal employment and military service. For each job held,
give your job title, agency/company name, and dates (period)
of employment.
b. For each job title, describe duties which required
exertion with or repeated movement of the wrist or hand.
Describe nature and frequency of motions required, and
average number of hours a day/week you did such work.
c. Give date employee entered on duty in job requiring
above duties. Also give the effective date(s) and descrip-
tion(s) of any changes in work assignments due to
employee's condition and indicate whether duty changes
resulted in changes in pay.
c. Describe hobbies, physical fitness or other activities
outside of work which also involved exertion or repeated
motions of wrist/hand. State the nature of each such activity,
years involved in each, and how many hours a week you
engaged in such.
d. If you have ever had an injury to the hand/arm/wrist,
or been diagnosed as having gout, arthritis, hypothyroidism,
diabetes, a tumor, or deformity of the hand/wrist, from/since
birth, describe the injury or condition, and state when injury
occurred or condition was found.
Send us copies of employee's:
2.
a. SF-1 71, Application for Employment;
b. Position description with physical requirements
for last job held;
e. Give a brief chronological history of your hand/wrist
problem. State which hand(s) are affected, when you first
experienced problems, nature of the problems and changes
over time to present, and dates and nature of medical care
obtained.
c. All available medical records, including report of
pre-employment examination;
d. SF-50s or equivalent documents for changes in
assignment/pay due to condition.
2.
Ask all doctors who treated you to send us a copy of re-
ports or notes describing the condition, testing, and treatment
given.
3.
Ask the doctor currently treating your condition to provide a detailed current medical report to include the following specifics:
a. Dates of examinations;
e. Treatment to date and prognosis;
f. Reasoned opinion expIaining any causal relationship
between the condition and your Federal civilian job.
b. Complete medical history of condition;
c. Medical diagnosis of condition;
It is MOST IMPORTANT that the doctor provide opinion as
to the likely nature of the physical effects attributable to
specified duties of your Federal job, and explain the medical
reasoning which supports the opinion as to cause.
d. Findings and test results, specifically including:
results of Phalen's and Tinel's Sign tests: physical
findings concerning sensation over palmar aspect
of first three and one-half digits, and dorsal aspect
of end joints of same digits, and any atrophy of the
Thenar Eminence; results of nerve conduction velocity,
and electromyographic testing;
Form CA-35H
For sale by the Superintendent of Documents, U.S. Government Printing Office. Washington. D.C. 20402
October 1987
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FROM EMPLOYING AGENCY
1. Review the employee's statement, giving the following
information:
a. Comment on the accuracy of the employee's state-
ment describing Federal job duties involving use of hand/
wrist.
b. Provide a day-to-day listing of leave and leave with-
out pay used by the employee due to carpal tunnel/wrist
problems.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE
Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'
Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or
aggravated the disease or illness.
The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial
effort. The attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and
Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be
given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off
each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation
Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your
Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information directly
to your supervisor.
Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post
card advising you of the case number. Use this number on all future correspondence about your claim.
If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management
(OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for the same
period of time.
HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your
statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN
IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.
NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS
OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists
to help you and the employee submit a claim in an organized and complete manner. The checklists will help the claims examiner
identify what information has been submitted and what is still outstanding.
Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:
1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and
2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to
mark and return with the completed package. The second checklist is for the employee to take to the physician.
In addition to describing the evidence required from the employee, the checklists describe the information to be submitted by the
employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2 to
forward them to OWCP within ten working days. Statements and documents required from the agency should be submitted with
the CA-2 whenever possible. Please use the checklist to note what information from the employing agency is enclosed,
unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements and documentation
are essential for the examiner to get a well rounded picture of the employment conditions.
We appreciate your cooperation in this effort.
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