United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.M., Appellant 

and 

U.S. POSTAL SERVICE, NORTHERN OHIO 

PERFORMANCE CLUSTER, Cleveland, OH, 

Employer 

__________________________________________ 

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Docket No. 16-0623 

Issued: July 19, 2016 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

COLLEEN DUFFY KIKO, Judge 

ALEC J. KOROMILAS, Alternate Judge 

JURISDICTION 

On February 12, 2016 appellant filed a timely appeal of a November 9, 2015 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 to consider the merits of the case.2

 1

 5 U.S.C. § 8101 et seq. 

2

 The Board notes that appellant submitted additional evidence after OWCP rendered its November 9, 2015 

decision. The Board’s jurisdiction is limited to reviewing the evidence that was before OWCP at the time of its final 

decision. Therefore, this additional evidence cannot be considered by the Board. 20 C.F.R. § 501.2(c)(1); Dennis E. 

Maddy, 47 ECAB 259 (1995); James C. Campbell, 5 ECAB 35, 36 n.2 (1952). Appellant may submit this evidence 

to OWCP, together with a formal request for reconsideration, pursuant to 5 U.S.C. § 8128(a) and 20 C.F.R. 

§ 10.606(b)(2). 
2

ISSUE 

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

September 16, 2015 causally related to the accepted employment incident. 

FACTUAL HISTORY 

On September 16, 2015 appellant, then a 52-year-old city carrier assistant, filed a 

traumatic injury claim (Form CA-1) alleging that, on that date, she sustained injuries when the 

wooden steps she was climbing shifted and collapsed while she was walking to a mailbox. She 

claimed that her left ankle and foot rolled under and she fell on top of lower leg/foot/ankle. 

Appellant stopped work on September 16, 2015. 

By letter dated October 2, 2015, OWCP informed appellant that the evidence in the 

record was insufficient to support her claim and that she must submit further evidence, including 

medical evidence, in support of her claim and afforded her 30 days to submit such evidence. 

Appellant responded to this letter and submitted a September 16, 2015 form report with 

an illegible signature from the Cleveland Clinic at Work listed diagnoses of left ankle sprain and 

thumb sprain and placed appellant on light duty. In October 1 and 21, 2015 form reports from 

the Cleveland Clinic at Work, with illegible signatures, indicated that appellant had a left ankle 

sprain. A duty status report of October 1, 2015 also contained an illegible signature and listed 

appellant’s work restrictions. The October 21, 2015 report indicated that appellant could return 

to full duty on the next regular shift. 

By decision dated November 9, 2015, OWCP denied appellant’s claim. It determined 

that, although she established that the employment incident occurred as alleged, the evidence did 

not establish a causal relationship between the accepted employment incident and a medical 

diagnosis. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of proof to establish the 

essential elements of his or her claim, including the fact that the individual is an employee of the 

United States within the meaning of FECA, that the claim was timely filed within the applicable 

time limitation period of FECA, that an injury was sustained in the performance of duty as 

alleged, and that any disability and/or specific condition for which compensation is claimed are 

causally related to the employment injury. These are the essential elements of each and every 

compensation claim regardless of whether the claim is predicated upon a traumatic injury or an 

occupational disease.3

 

In order to determine whether an employee actually sustained an injury in the 

performance of duty, OWCP begins with an analysis of whether fact of injury has been 

established. Generally, fact of injury consists of two components, which must be considered in 

conjunction with one another. The first component to be established is that the employee 

 3 Jussara L. Arcanjo, 55 ECAB 281, 283 (2004). 
3

actually experienced the employment incident or exposure, which is alleged to have occurred.4

 

In order to meet his or her burden of proof to establish the fact that he or she sustained an injury 

in the performance of duty, an employee must submit sufficient evidence to establish that he or 

she actually experienced the employment injury or exposure at the time, place, and in the manner 

alleged.5

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

generally can be established only by medical evidence.6

 The medical evidence required to 

establish causal relationship is usually rationalized medical evidence. Rationalized medical 

opinion evidence is medical evidence which includes a physician’s rationalized opinion on the 

issue of whether there is a causal relationship between the claimant’s diagnosed condition and 

the implicated employment factors. The opinion of the physician must be based on a complete 

factual and medical background of the claimant, must be one of reasonable medical certainty, 

and must be supported by medical rationale explaining the nature of the relationship between the 

diagnosed condition and the specific employment factors identified by the claimant.7

ANALYSIS 

OWCP determined that appellant had established that the employment incident occurred 

as alleged. However, it denied her claim as she failed to submit rationalized medical evidence 

describing how the accepted incident caused a diagnosed condition. 

The Board finds that appellant failed to submit medical evidence establishing a causal 

relationship between the accepted incident of September 16, 2015 and a medical diagnosis. 

Neither the fact that a disease or condition manifests itself during a period of employment nor the 

belief that the disease or condition was caused or aggravated by the employment factors or 

incident is sufficient to establish causal relationship.8 

The Board notes that the record contains no medical report with a legible signature. The 

Board has held that medical reports may not be considered as probative medical evidence if there 

is no indication that the person completing the report qualifies as a physician as defined in 

5 U.S.C. § 8102(2).9

 Reports lacking medical identification do not constitute probative medical 

evidence.10 

 4 See Federal (FECA) Procedure Manual, Part 2 -- Claims, Fact of Injury, Chapter 2.803(2)(a) (August 2012). 

5 Linda S. Jackson, 49 ECAB 486 (1998). 

6 John J. Carlone, 41 ECAB 354 (1989); Horace Langhorne, 29 ECAB 820 (1978). 

7 Judith A. Peot, 46 ECAB 1036 (1995); Ruby I. Fish, 46 ECAB 276 (1994). 

8 See Dennis M. Mascarenas, 49 ECAB 215 (1997). 

9 B.A., Docket No. 15-1384 (issued September 15, 2015). 

10 V.R., Docket No. 14-1695 (issued January 9, 2015). 
4

An award of compensation may not be based on surmise, conjecture, or speculation.11 To 

support a claim for compensation, the evidence should offer a medically sound explanation of 

how the claimed work event caused or aggravated the claimed condition.12 

Appellant, therefore, did not meet her burden of proof to establish an injury causally 

related to the accepted work incident which occurred on September 16, 2015. 

CONCLUSION 

The Board finds that appellant did not meet her burden of proof to establish that she 

sustained an injury on September 16, 2015, causally related to the accepted employment 

incident. 

ORDER 

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’ 

Compensation Programs dated November 9, 2015 is affirmed. 

Issued: July 19, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 11 D.I., 59 ECAB 158 (2007); Ruth R. Price, 16 ECAB 688, 691 (1965). 

12 K.H., Docket No. 15-1809 (issued January 7, 2016).