§ 15.105 What information and evidence should be provided to DOL to substantiate an FTCA administrative claim? ( a ) *Personal injury.* In support of a claim for personal injury, including pain and suffering, the claimant is required to submit the following evidence or information: ( 1 ) A written report by the attending physician or dentist setting forth the nature and extent of the injury, nature and extent of treatment, any degree of temporary or permanent impairment, the prognosis, period of hospitalization, if any, and any diminished earning capacity. In addition, the claimant may be required to submit to a physical or mental examination by a physician employed or designated by the Department or another Federal agency. A copy of the report of the examining physician shall be made available to the claimant upon the claimant's written request.
( 2 ) Itemized bills for medical, dental and hospital, or any other, expenses incurred or itemized receipts of payment for such expenses.
( 3 ) If the prognosis reveals the necessity for future treatment, a statement of expected expenses for such treatment.
( 4 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the personal injury or the damages claimed.
( b ) *Death.* In support of a claim based on death, the claimant may be required to submit the following evidence or information: ( 1 ) An authenticated death certificate, an autopsy report and or other competent evidence that includes cause or causes of death, date of death, and age of the decedent.
( 2 ) Decedent's employment or occupation at the time of death, including his or her monthly or yearly salary or earnings (if any), and the duration of his or her last employment or occupation.
( 3 ) Full name, address, birth date, kinship and marital status of the decedent's survivors, including identification of those survivors who were dependent for support upon the decedent at the time of his or her death.
( 4 ) Degree of support afforded by the decedent to each survivor dependent upon him or her for support at the time of his or her death.
( 5 ) Decedent's general physical and mental condition before his or her death.
( 6 ) Itemized bills for medical and burial expenses incurred by reason of the incident causing death, or itemized receipts of payment for such expenses.
( 7 ) If damages for pain and suffering prior to death are claimed, a physician's detailed statement specifying the injuries suffered, duration of pain and suffering, any drugs administered for pain, and the decedent's physical condition in the interval between injury and death.
( 8 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the death or damages claimed.
( c ) *Property damages.* In support of a claim for injury to or loss of property, real or personal, the claimant may be required to submit the following evidence or information with respect to each item of property: ( 1 ) Proof of ownership.
( 2 ) A detailed statement of the amount claimed.
( 3 ) An itemized receipt of payment for necessary repairs or itemized written estimates of the cost of such repairs.
( 4 ) A statement listing date of purchase, purchase price, and salvage value where repair is not economical.
( 5 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the injury to or loss of property or the damages claimed.
( d ) *Loss of income.* In support of a claim based on loss of income, the claimant may be required to submit the following evidence or information: ( 1 ) A written statement from his or her employer showing actual time lost from employment, whether he or she is a full or part-time employee, and wages or salary actually lost.
( 2 ) If the claimant is self-employed, documentary evidence showing the amount of earnings lost such as: ( i ) Income tax returns for several years prior to the injury in question and the year in which the injury occurred may be used to indicate or measure lost income; or
( ii ) A statement of the actual or projected cost for the claimant to hire someone else to do the same work he or she was doing at the time of injury.
( 3 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the personal injury or the damages claimed.