Notice of Occupational Disease
U. S. Department of Labor
Reset
Print
and Claim for Compensation
Office of Workers' Compensation Programs
Employee: Please complete all boxes 1 - 18 below. Do not complete shaded areas.
Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.
Employee Data
1. Name of Employee (Last, First, Middle)
2. Social Security Number
Mo.
Day
Yr.
4. Sex
5. Home telephone
6. Grade as of date
3. Date of birth
of last exposure
Step
Level
(
)
8. Dependents
7. Employee's home mailing address (include street address, city, state, and ZIP code)
Wife, Husband
Children under 18 years
City
State
ZIP Code
Other
Claim Information
9. Employee's occupation
a. Occupation code
10. Location where you worked when disease or illness occurred (include street address, city, state, and ZIP code)
11. Date you first became
aware of disease
or illness
City
State
ZIP Code
Mo.
Day
Yr.
12. Date you first realized
13. Explain the relationship to your employment, and why you came to this realization
Day
Yr.
Mo.
the disease or illness
was caused or aggravated
by your employment
14. Nature of disease or illness
OWCP Use - NOI Code
b. Type code
c. Source code
15. If this notice and claim was not filed with the employing agency within 30 days after date shown above in item #12, explain the reason for the
delay.
16. If the statement requested in item I of the attached instructions is not submitted with this form, explain reason for delay.
17. If the medical reports requested in item 2 of attached instructions are not submitted with this form, explain reason for delay.
Employee Signature
18. I certify, under penalty of law, that the disease or illness described above was the result of my employment with the United States
Government, and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication.
I hereby claim medical treatment, if needed, and other benefits provided by the Federal Employees' Compensation Act.
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.
Date
Signature of employee or person acting on his/her behalf
Have your supervisor complete the receipt attached to this form and return it to you for your 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 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.
Form CA-2
For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC 20402
Rev. Jan. 1997
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