United States Department of Labor

Employees’ Compensation Appeals Board

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J.F., Appellant

and

DEPARTMENT OF HOMELAND SECURITY, 

U.S. COAST GUARD, U.S. COAST GUARD 

YARD, Baltimore, MD, Employer

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Docket No. 23-0492

Issued: November 8, 2023

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

PATRICIA H. FITZGERALD, Deputy Chief Judge

JAMES D. McGINLEY, Alternate Judge

JURISDICTION

On February 21, 2023 appellant filed a timely appeal from a November 7, 2022 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 has met his burden of proof to establish an injury in the 

performance of duty on September 19, 2022, as alleged.

FACTUAL HISTORY

On September 23, 2022 appellant, then a 37-year-old pipefitter, filed a traumatic injury 

claim (Form CA-1) alleging that on September 19, 2022 he fractured his coccyx when he slipped 

1

5 U.S.C. § 8101 et seq.
2

and fell on a gangway while in the performance of duty. On the reverse side of the claim form,

his supervisor acknowledged that he was in the performance of duty when injured and that the

statements of the employee and/or witnesses comported with his knowledge of the facts. Appellant 

stopped work on September 19, 2022 and returned to full-time modified work with restrictions on 

September 22, 2022.

In an undated attending physician’s report (Form CA-20), Charles Bethmann, a physician 

assistant, noted a history of appellant falling down steps on September 19, 2022. He diagnosed a 

compression injury of the spine and a coccyx fracture. Mr. Bethmann checked a box marked “Yes”

indicating that the conditions were related to an employment activity.

In a September 19, 2022 form report, Jessica Martin, a physician assistant, noted that 

appellant related a history that he slipped and fell down wet gangway steps while at work that day. 

She diagnosed coccyx pain and indicated that he was not fit for duty. 

In a work status note of even date, Mr. Bethmann advised that appellant remain out of 

work. He anticipated that he would be able to return to restricted-duty work on 

September 22, 2022.

In a September 23, 2022 work status note, Maryam Messforosh, a physician assistant, 

released appellant to return to work with restrictions including no lifting, pushing, or pulling 

greater than 10 pounds occasionally and no more than occasional standing, walking, overhead 

lifting, or repetitive use of the hands.

In a September 30, 2022 development letter, OWCP informed appellant of the deficiencies 

of his claim. It advised him of the type of factual and medical evidence required and provided a 

questionnaire for his completion. OWCP afforded appellant 30 days to submit the necessary 

evidence. 

OWCP thereafter received a September 19, 2022 medical report from Dr.Walter Gianelle, 

a Board-certified emergency medicine specialist, who noted that appellant related complaints of 

lower back pain after a slip and fall on steps at work. Dr. Gianelle further noted that he landed on 

his low back and coccyx area. On physical examination, he documented tenderness to palpation 

of the coccyx and paravertebral muscles from L4 to S1. Dr. Gianelle obtained x-rays, which 

revealed a fracture of the coccyx. He diagnosed a closed fracture of the coccyx.

In September 23 and 30, 2022 follow-up reports, Dr. Gianelle noted that appellant related 

ongoing back pain and that he had been unable to sit at work due to increased pain. He further 

noted that he “fell at work from six steps and has broken the coccyx.” Dr. Gianelle diagnosed 

fracture of coccyx with routine healing.

Ms. Messforosh, in a September 30, 2022 work status note, recommended ongoing work 

restrictions. 

By decision dated November 7, 2022, OWCP denied appellant’s traumatic injury claim, 

finding that he had not submitted sufficient evidence to establish that the events occurred as 

alleged. Consequently, it found that he had not met the requirements to establish an injury as 

defined by FECA.
3

LEGAL PRECEDENT

An employee seeking benefits under FECA2 has the burden of proof to establish the 

essential elements of his or her claim, including 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 of FECA,3that an injury was sustained in the performance of duty as alleged, and that 

any disability or medical condition for which compensation is claimed is causally related to the 

employment injury.4 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.5

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. There 

are two components involved in establishing fact of injury. The first component is whether the

employee actually experienced the employment incident at the time and place, and in the manner 

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

can be established only by medical evidence.6 

To establish that an injury occurred as alleged, the injury need not be confirmed by 

eyewitnesses, but the employee’s statements must be consistent with the surrounding facts and 

circumstances and his or her subsequent course of action.7 In determining whether a case has been 

established, such circumstances as late notification of injury, lack of confirmation of injury, and 

failure to obtain medical treatment may, if otherwise unexplained, cast substantial doubt on the 

employee’s statements. The employee has not met his or her burden when there are such 

inconsistencies in the evidence as to cast serious doubt on the validity of the claim. 8 An 

employee’s statements alleging that an injury occurred at a given time and in a given manner is of 

great probative value and will stand unless refuted by strong or persuasive evidence. 9

2

Id.

3 F.H., Docket No.18-0869 (issued January 29, 2020); J.P., Docket No. 19-0129 (issued April26, 2019); JoeD. 

Cameron, 41 ECAB 153 (1989). 

4 L.C., Docket No. 19-1301 (issued January 29, 2020); J.H., Docket No. 18-1637 (issued January 29, 2020); 

James E. Chadden, Sr., 40 ECAB 312 (1988).

5 P.A., Docket No. 18-0559 (issued January 29, 2020); K.M., Docket No. 15-1660 (issued September 16, 2016); 

Delores C. Ellyett, 41 ECAB 992 (1990).

6 T.H., Docket No. 19-0599 (issued January 28, 2020); K.L., Docket No. 18-1029 (issued January 9, 2019); John J. 

Carlone, 41 ECAB 354 (1989).

7

S.W., Docket No. 17-0261(issued May 24, 2017).

8 D.F., Docket No. 21-0825 (issued February 17, 2022); Betty J. Smith, 54 ECAB 174 (2002).

9 D.F., id.; see also M.C., Docket No. 18-1278 (issued March 7, 2019); D.B., 58 ECAB 464, 466-67 (2007).
4

ANALYSIS

The Board finds that appellant has met his burden of proof to establish that a traumatic 

incident occurred in the performance of duty on September 19, 2022, as alleged. 

In his September 23, 2022 Form CA-1, appellant indicated that on September 19, 2022 he

slipped and fell on a gangway and fractured his coccyx. His supervisor acknowledged on the 

reverse side of the claim form that he was injured in the performance of duty on February 19, 2022 

and that his knowledge of the facts about the injury comported with statements of the employee 

and/or witnesses. 

Appellant also provided reports from an emergency department dated September 19, 2022, 

the day of the employment incident. In a September 19, 2022 medical report, Dr. Gianelle noted 

that appellant related that he slipped on steps at work and landed on his coccyx region. In a form 

report of even date, Ms. Martin noted that he related that he slipped and fell down wet gang-way 

steps on that date. Dr. Gianelle provided a history of injury provided additional details and 

discussion of the employment incident, and further substantiated his account of the September 19, 

2022 employment incident. In an undated Form CA-20, Mr. Bethann indicated that appellant fell 

down steps. The injuries appellant claimed, and the initial medical treatment received, are all 

consistent with the facts and circumstances he set forth in his Form CA-1.10 There are no 

inconsistencies in the evidence that cast serious doubt upon the validity of the claim. Therefore, 

the Board finds that she has established a traumatic incident in the performance of duty on 

September 19, 2022, as alleged.11

As appellant has established that an incident occurred in the performance of duty on 

September 19, 2022, as alleged, the question becomes whether the incident caused an injury.

12

 As 

OWCP found that he had not established fact of injury, it did not evaluate the medical evidence. 

The case must, therefore, be remanded for consideration of the medical evidence of record.13 After 

such further development as deemed necessary, OWCP shall issue a de novo decision addressing 

whether appellant has met his burden of proof to establish an injury causally related to the accepted 

September 19, 2022 employment incident.

CONCLUSION

The Board finds that appellant has met his burden of proof to establish that a traumatic 

incident occurred in the performance of duty on September 19, 2022, as alleged. The Board further 

finds that this case is not in posture for decision regarding whether he has established an injury 

causally related to the accepted September 19, 2022 employment incident.

10 See F.F., Docket No. 22-0266 (issued September 27, 2022); C.H., Docket No. 19-1781 (issued 

November 13, 2020).

11 C.B., Docket No. 21-0670 (issued January 27, 2022).

12 M.A., Docket No. 19-0616 (issued April 10, 2020); C.M., Docket No. 19-0009 (issued May 24, 2019) 

13 See L.D., Docket No. 16-0199 (issued March 8, 2016).
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ORDER

IT IS HEREBY ORDERED THAT the November 7, 2022 decision of the Office of 

Workers’ Compensation Programs is reversed in part and set aside in part. The case is remanded 

for further proceedings consistent with this decision of the Board. 

Issued: November 8, 2023

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

James D. McGinley, Alternate Judge

Employees’ Compensation Appeals Board