United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.A., Appellant 

and 

DEPARTMENT OF THE NAVY, CHILD 

DEVELOPMENT CENTER, JOINT BASE 

ANACOSTIA-BOLLING, Washington, DC, 

Employer 

__________________________________________ 

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Docket No. 15-1092 

Issued: August 3, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

COLLEEN DUFFY KIKO, Judge 

JURISDICTION 

On April 9, 2015 appellant filed a timely appeal from a December 10, 2014 merit 

decision of the Office of Workers’ Compensation Programs (OWCP). Pursuant to the Federal 

Employees’ Compensation Act1 (FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has 

jurisdiction over the merits of this case. 

ISSUE 

The issue is whether appellant met her burden of proof to establish a back injury on 

December 19, 2013 while in the performance of duty. 

On appeal, appellant contends that she sustained an employment-related back injury for 

which she received medical treatment in an emergency room as directed by the employing 

establishment. 

 

 1 5 U.S.C. § 8101 et seq.
2

FACTUAL HISTORY 

On January 13, 2014 appellant, then a 51-year-old child development program technician, 

filed a traumatic injury claim alleging that on December 19, 2013 she sustained a back injury in 

the employing establishment’s kitchen. She stated that a coworker was opening an oven door 

and accidently hit her in the back with the door. Appellant stopped work on the date of injury 

and returned to work on December 24, 2013. 

Appellant submitted emergency room records dated December 19, 2013 from Calvert 

Memorial Hospital. In a note, Luis DaConceicao, a certified physician assistant, advised that 

appellant could return to work in two days. Discharge instructions indicated that appellant was 

treated by Mr. DaConceicao and provided a diagnosis of back pain and information about 

appellant’s medication and follow-up instructions. 

An order requisition form dated December 20, 2013 from Bayside Primary Care 

contained an unknown signature. The form requested studies and stated that appellant would be 

off work through December 23, 2013 due to an injury. 

A choice of doctor statement dated December 20, 2013 indicated that appellant chose 

Dr. Dhimitri E. Gross, Board-certified in family medicine, as her physician. 

A December 20, 2013 prescription sheet from Walmart Pharmacy indicated that appellant 

was prescribed Cyclobenzapr to treat her muscle spasm. 

By letter dated February 7, 2014, OWCP notified appellant of the deficiencies of her 

claim and afforded her 30 days to submit additional medical evidence. It also requested that the 

employing establishment submit medical evidence, if appellant had been treated at its medical 

facility. 

Appellant submitted additional emergency room records dated December 19, 2013 from 

Calvert Memorial Hospital. In a report and progress note, Dr. William A. White, a Boardcertified internist, provided a history which included, among other things, that on December 19, 

2013 appellant was hit on the left lower back by an industrial-type oven door at work. The 

report also provided examination findings and laboratory urinalysis test results. Appellant was 

diagnosed as having back pain. She could return to work in two days with restrictions. 

In a December 19, 2013 lumbar x-ray report, Dr. Peter M. Mamalakis, a Board-certified 

radiologist, found no acute fracture or dislocation. 

In an April 15, 2014 decision, OWCP accepted that the December 19, 2013 incident 

occurred as alleged. However, it denied appellant’s claim as the medical evidence did not 

establish a causal relationship between her back condition and the accepted employment 

incident. 

On May 7, 2014 appellant requested a review of the written record by an OWCP hearing 

representative. 

In a December 20, 2013 report, Dr. Gross provided a history of the accepted 

December 19, 2013 employment incident, and appellant’s medical treatment, and social and 
3

family background. He reported findings on physical examination and diagnosed back contusion 

and muscle spasm. 

In a December 10, 2014 decision, an OWCP hearing representative affirmed the April 15, 

2014 decision. He found that the medical evidence was insufficient to establish a back injury 

causally related to the accepted December 19, 2013 employment incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA2

 has the burden of proof to establish the 

essential elements of his or her claim by the weight of the reliable, probative, and substantial 

evidence3

 including that he or she sustained an injury in the performance of duty and that any 

specific condition or disability for work for which he or she claims compensation is causally 

related to that employment injury.4

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether fact of injury has been established.5

 

There are two components involved in establishing the fact of injury. First, the employee must 

submit sufficient evidence to establish that she actually experienced the employment incident at 

the time, place, and in the manner alleged.6

 

The second component is whether the employment incident caused a personal injury and 

generally can be established only by medical evidence.7

 The evidence required to establish 

causal relationship is rationalized medical opinion evidence, based upon complete factual and 

medical background, showing a causal relationship between the claimed condition and the 

identified factors.8

 The belief of the claimant that a condition was caused or aggravated by the 

employment is insufficient to establish a causal relationship.9

ANALYSIS 

The Board finds that appellant has not met her burden of proof to establish a traumatic 

injury caused by the accepted December 19, 2013 employment incident. Appellant failed to 

submit sufficient medical evidence to establish that she had a back injury causally related to the 

accepted employment incident. 

 

 2 5 U.S.C. §§ 8101-8193. 

 3 J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968). 

 4 G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

 5 S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005). 

 6 Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968). 

 7 John J. Carlone, 41 ECAB 354 (1989); see 5 U.S.C. § 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 10.5(q) 

(traumatic injury and occupational disease defined, respectively). 

 8 Lourdes Harris, 45 ECAB 545 (1994); see Walter D. Morehead, 31 ECAB 188 (1979). 

 9 Kathryn Haggerty, 45 ECAB 383, 389 (1994). 
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Dr. Gross’ December 20, 2013 report found that appellant had a back contusion and 

muscle spasms. He provided a history of the accepted December 19, 2013 employment incident, 

but failed to provide an opinion stating that the diagnosed back conditions were caused or 

aggravated by the accepted employment incident. Medical evidence that does not offer any 

opinion regarding the cause of an employee’s condition is of limited probative value.10

Dr. Mamalakis’ December 19, 2013 lumbar x-ray report found no acute fracture or 

dislocation. He did not opine that appellant had a lumbar condition causally related to the 

accepted employment incident. 

The December 19, 2013 report and progress note of Dr. White found that appellant had 

back pain and that she could return to work in two days with restrictions. The Board finds that 

Dr. White’s diagnosis of back pain is a description of a symptom rather than a clear diagnosis of 

the medical condition.11

The December 19, 2013 note and discharge instructions from Mr. DaConceicao, a 

physician assistant, which noted that appellant could return to work in two days, has no probative 

medical value as a physician assistant is not a physician as defined under FECA.12 

The December 20, 2013 order requisition form from Bayside Primary Care which 

contained an unknown signature and excused appellant from work through December 23, 2013 

due to an injury is insufficient to establish the claim. A report that is unsigned or bears an 

illegible signature lacks proper identification and cannot be considered probative medical 

evidence as the author cannot be identified as a physician.13 

The remaining medical evidence of record, including a choice of doctor statement and 

prescription sheet, does not contain a rationalized medical opinion by a physician on the cause of 

appellant’s claimed condition, and thus, is insufficient to establish appellant’s claim. 

Therefore, the Board finds that there is insufficient medical evidence to establish that 

appellant sustained a back injury causally related to the accepted December 19, 2013 

employment incident. 

On appeal, appellant contended that she sustained an employment-related back injury for 

which she received medical treatment in an emergency room as directed by the employing 

establishment. A properly executed CA-16 form can create a contractual agreement for payment 

of medical expense, even if the claim is not accepted.14 Although there is evidence of record that 

 10 See K.W., 59 ECAB 271 (2007); A.D., 58 ECAB 149 (2006); Jaja K. Asaramo, 55 ECAB 200 (2004); 

Michael E. Smith, 50 ECAB 313 (1999). 

11 The Board has consistently held that pain is a symptom, rather than a compensable medical diagnosis. See P.S., 

Docket No. 12-1601 (issued January 2, 2013); C.F., Docket No. 08-1102 (issued October 10, 2008). 

12 A.C., Docket No. 08-1453 (issued November 18, 2008). Under FECA, a physician includes surgeons, 

podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the 

scope of their practice as defined by State law. 5 U.S.C. § 8101(2). See also Charley V.B. Harley, 2 ECAB 208, 

211 (1949) (where the Board held that medical opinion, in general, can only be given by a qualified physician). 

 13 Thomas L. Agee, 56 ECAB 465 (2005); Richard F. Williams, 55 ECAB 343 (2004). 

14 See Val D. Wynn, 40 ECAB 666 (1989); 20 C.F.R. § 10.300. 
5

appellant received emergency medical treatment on the date of occurrence and the employing 

establishment does not controvert the claim, the Board notes that a Form CA-16 is not contained 

in the record. However, the Board notes that, under 5 U.S.C. § 8103, OWCP also has broad 

discretion to approve medical care which it finds necessary and reasonable in cases of emergency 

or other unusual circumstances. Upon return of the case record, OWCP shall determine whether 

appellant’s initial medical care in the hospital emergency room should be authorized pursuant to 

20 C.F.R. § 10.304, which provides that, in cases involving emergencies or unusual 

circumstances, OWCP may authorize treatment.15 

Appellant may submit new evidence or argument with a written request for 

reconsideration to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128(a) 

and 20 C.F.R. §§ 10.605 through 10.607. 

CONCLUSION 

The Board finds that appellant has failed to meet her burden of proof to establish a back 

injury on December 19, 2013 while in the performance of duty. 

ORDER 

IT IS HEREBY ORDERED THAT the December 10, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: August 3, 2015 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 15 See, e.g., A.S., Docket No. 15-101 (issued April 24, 2015) (as there was no Form CA-16 of record, the Board 

remanded this aspect of the case for OWCP to determine whether appellant’s initial care in the hospital emergency 

room should be authorized, pursuant to 20 C.F.R. § 10.304).