Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs Page 2

Download a blank fillable Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Official Supervisor's Report of Occupational Disease: Please complete information requested below
Supervisor's Report
19. Agency name and address of reporting office (include street address, city, state, and ZIP Code)
OWCP Agency Code
OSHA Site Code
City
State
ZIP Code
20. Employee's duty station (include street address, city, state, and ZIP code)
City
State
ZIP Code
22. Regular
21. Regular
a.m.
a.m.
work
work
schedule
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
p.m.
To:
p.m.
hours From:
23. Name and address of physician first providing medical care (include city, state, ZIP code)
24. First date
Mo.
Day
Yr
medical
care received
25. Do medical reports
Yes
No
show employee is
City
State
ZIP Code
disabled for work?
26. Date employee
Mo.
27. Date and
Yr.
Mo.
Yr.
Day
Day
a.m.
hour employee
first reported
Time
p.m.
stopped work
condition to
supervisor
29. Date employee was last
Mo.
28. Date and
Mo.
Yr.
Day
Yr.
Day
a.m.
hour employee's
exposed to conditions
Time
p.m.
alleged to have caused
pay stopped
disease or illness
30. Date
Mo.
Day
Yr.
a.m.
returned
to work
Time
p.m.
31. If employee has returned to work and work assignment has changed, describe new duties
32. Employee's Retirement Coverage
FERS
Other, (Specify)
CSRS
33. Was injury caused
34. Name and address of third party (include street address, city, state, and ZIP code)
by third party?
Yes
No
If "No,"
go to
City
State
ZIP Code
Item 34.
Signature of Supervisor
35. A supervisor 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.
I certify that the information given above and that furnished by the employee on the reverse of this form is true to the best of my
knowledge with the following exception:
Name of Supervisor (Type or print)
Signature of Supervisor
Date
Supervisor's Title
Office phone
Form CA-2
Rev.Jan.1997

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Ca - U. S. Department Of Labor - 2 Notice Of Occupational Disease And Claim For Compensation Form Ca - U. S. Department Of Labor - 2 Notice Of Occupational Disease And Claim For Compensation Legal
Form 3b - Employee's First Notice Of Occupational Disease And Claim For Compensation Form 3b - Employee's First Notice Of Occupational Disease And Claim For Compensation Business
Form 3 - Employee's First Notice Of Accidental Injury And Claim For Compensation Form 3 - Employee's First Notice Of Accidental Injury And Claim For Compensation Legal
Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2015 Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2015 Financial
Form 18.2 - Notice Of Hearing On Petition For Adoption Form 18.2 - Notice Of Hearing On Petition For Adoption Legal
Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2016 Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2016 Financial
Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2014 Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2014 Financial
Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2009 Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2009 Financial
Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2010 Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2010 Financial
Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2008 Form Molt-2 - Marshall County Occupational License Tax Return For Schools - 2008 Financial

Related Categories

Parent category: Legal
Download
Go
Page of 4