Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs Page 3
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4Disability Benefits for Employees under the Federal Employees' Compensation Act (FECA)
The first three days in a non-pay status are waiting days, and
The FECA, which is administered by the Office of Workers'
no compensation is paid for these days unless the period of
Compensation Programs (OWCP), provides the following
disability exceeds 14 calendar days, or the employee has
general benefits for employment-related occupational disease
suffered a permanent disability. Compensation for total
or illness:
disability is generally paid at the rate of 2/3 of an employee's
salary if there are no dependents, or 3/4 of salary if there are
(1) Full medical care from either Federal medical officers and
one or more dependents.
hospitals, or private hospitals or physicians of the
employee's choice.
An employee may use sick or annual leave rather than LWOP
(2) Payment of compensation for total or partial wage loss.
while disabled. The employee may repurchase leave used
for approved periods. Form CA-7b, available from the
(3) Payment of compensation for permanent impairment of
personnel office, should be studied BEFORE a decision is
made to use leave.
certain organs, members, or functions of the body (such as
loss or loss of use of an arm or kidney, loss of vision, etc.),
or for serious disfigurement of the head, face, or neck.
If an employee is in doubt about compensation benefits, the
OWCP District Office servicing the employing agency should
(4) Vocational rehabilitation and related services where
be contacted. (Obtain the address from your employing
necessary.
agency.)
For additional information, review the regulations governing the
administration of the FECA (Code of Federal Regulations, Title
20, Chapter 1) or Chapter 810 of the Office of Personnel
Management's Federal Personnel Manual.
Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)
Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be
verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the
claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to
consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other
government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services.
(5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational
rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be
given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to
determine whether benefits are being paid properly, including whether prohibited dual Payments are being made, and, where appropriate, to
pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7)
Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and
other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal
government, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing
of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the
processing and adjudication of the claim you filed under the FECA.
Receipt of Notice of Occupational Disease or Illness
This acknowledges receipt of notice of disease or illness sustained by:
(Name of injured employee)
I was first notified about this condition on (Mo., Day, Yr.)
At (Location)
Title
Date (Mo., Day, Yr.)
Signature of Official Superior
This receipt should be retained by the employee as a record that notice was filed.
Form CA-2
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