Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs Page 4
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4INSTRUCTIONS FOR COMPLETING FORM CA-2
Complete all items on your section of the form. If additional space is required to explain or clarify any point, attach a supplemental statement
to the form. in addition to the information requested on the form, both the employee and the supervisor are required to submit additional
evidence as described below. If this evidence is not submitted along with the form, the responsible party should explain the reason for the
delay and state when the additional evidence will be submitted.
Employee (or person acting on the Employee's behalf)
Complete items
through 18 and submit the form to the employee's supervisor along with the statement and medical reports described below.
1
Be sure to obtain the Receipt of Notice of Disease or Illness completed by the supervisor at the time the form is submitted.
2) Medical report
1) Employee's statement
In a separate narrative statement attached to the form, the
a) Dates of examination or treatment.
employee must submit the following information:
a) A detailed history of the disease or illness from the date it
b) History given to the physician by the employee.
started.
c) Detailed description of the physician's findings.
b) Complete details of the conditions of employment which are
believed to be responsible for the disease or illness.
d) Results of x-rays, laboratory tests, etc.
c)
A description of specific exposures to substances or stress-
e) Diagnosis.
ful conditions causing the disease or illness, including
locations where exposure or stress occurred, as well as
f) Clinical course of treatment.
the number of hours per day and days per week of such
exposure or stress.
g) Physician's opinion as to whether the disease or illness
was caused or aggravated by the employment, along with
d) Identification of the part of the body affected. (If disability
an explanation of the basis for this opinion. (Medical
is due to a heart condition, give complete details of all
reports that do not explain the basis for the physician's
activities for one week prior to the attack with particular
opinion are given very little weight in adjudicating the
attention to the final 24 hours of such period.)
claim.)
e) A statement as to whether the employee ever suffered a
3) Wage loss
similar condition. if so, provide full details of onset,
history, and medical care received, along with names and
If you have lost wages or used leave for this illness, Form
CA-7 should also be submitted.
addresses of physicians rendering treatment.
Supervisor (Or appropriate official in the employing agency)
At the time the form is received, complete the Receipt of Notice of Disease or Illness and give it to the employee. In addition to completing items
19 through 34, the supervisor is responsible for filling in the proper codes in shaded boxes a, b, and c on the front of the form. If medical expense
or lost time is incurred or expected, the completed form must be sent to OWCP within ten working days after it is received. In a separate narrative
statement attached to the form, the supervisor must:
c) Attach a record of the employee's absence from work caused
a) Describe in detail the work performed by the employee.
by any similar disease or illness. Have the employee state the
Identify fumes, chemicals, or other irritants or situations
reason for each absence.
that the employee was exposed to which allegedly caused
the condition. State the nature, extent, and duration of the
d) Attach statements from each co-worker who has first-hand
exposure, including hours per days and days per week,
knowledge about the employee's condition and its cause. (The
requested above.
co-workers should state how such knowledge was obtained.)
b) Attach copies of all medical reports (including x-ray reports
e) Review and comment on the accuracy of the employee's state-
and laboratory data) on file for the employee.
ment requested above.
The supervisor should also submit any other information or evidence pertinent to the merits of this claim.
Item Explanation: Some of the items on the form which may require further clarification are explained below.
14. Nature of the disease or illness
24. First date medical care received
Give a complete description of the disease or illness. Specify
The date of the first visit to the physician listed in item 23.
the left or right side if applicable (e.g., rash on left leg; carpal
tunnel syndrome, right wrist).
19. Agency name and address of reporting office
32. Employee's Retirement Coverage.
The name and address of the office to which correspondence
Indicate which retirement system the employee is covered
from OWCP should be sent (if applicable, the address of the
under.
personnel or compensation office).
33. Was the injury caused by third party?
23. Name and address of physician first providing
A third party is an individual or organization (other than the
medical care
injured employee or the Federal government) who is liable for
The name and address of the physician who first provided
the disease. For instance, manufacturer of a chemical to which
medical care for this injury. If initial care was given by a
an employee was exposed might be considered a third party if
nurse or other health professional (not a physician) in the
improper instructions were given by the manufacturer for use of
employing agency's health unit or clinic, indicate this on a
the chemical.
separate sheet of paper.
Employing Agency - Required Codes
Box a (Occupational Code), Box b. (Type Code), Box c
OWCP Agency Code
This is a four digit (or four digit two letter) code used by OWCP
(Source Code), OSHA Site Code
The Occupational Safety and Health Administration (OSHA)
to identify the employing agency. The proper code may be obtained
requires all employing agencies to complete these items when
from your personnel or compensation office, or by contacting OWCP.
reporting an injury. The proper codes may be found in OSHA
Booklet 2014, Record Keeping and Reporting Guidelines.
Form CA-2
• U.S. GPO: 2001480-204/59062
Rev.Jan.1997
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