If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or 

modifications, please contact OWCP.

Notice of Occupational Disease

and Claim for Compensation

Employee: Please complete all boxes 1 - 18 below. Do not complete shaded areas.

Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.

1. Name of Employee (Last, First, Middle) 2. Social Security Number

3. Date of birth Mo. Day Yr. 4. Gender 5. Home telephone 6. Grade as of date

of last exposure Level Step

7. Employee's home mailing address (include street address, city, state, and ZIP code) 8. Dependents

Wife, Husband

Children under 18 years

Other

9. Employee's occupation

10. Location where you worked when disease or illness occurred (include street address, city, state, and ZIP code) 11. Date you first became

aware of disease

or illness

Mo. Day Yr.

12. Date you first realized 13. Explain the relationship to your employment, and why you came to this realization

the disease or illness Mo. Day Yr.

was caused or aggravated

by your employment

14. Nature of disease or illness

15. If this notice and claim was not filed with the employing agency within 30 days after date shown above in item #12, explain the reason for the delay.

16. If the statement requested in item I of the attached instructions is not submitted with this form, explain reason for delay.

17. If the medical reports requested in item 2 of attached instructions are not submitted with this form, explain reason for delay.

18. I certify, under penalty of law, that the disease or illness described above was the result of my employment with the United States

Government, and that it was not caused by my willful misconduct, intent to injure myself or another person, nor by my intoxication.

I hereby claim medical treatment, if needed, and other benefits provided by the Federal Employees' Compensation Act.

I hereby authorize any physician or hospital (or any other person, institution, corporation, or government, agency) to furnish any

desired information to the U.S. Department of Labor, Office of Workers' Compensation Programs (or to its official representative).

This authorization also permits any official representative of the Office to examine and to copy any records concerning me.

Signature of employee or person acting on his/her behalf Date

Have your supervisor complete the receipt attached to this form and return it to you for your records.

Any person who knowingly makes any false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation

as provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies

as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.

Form CA-2

For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC 20402 Rev. October 2018

Employee Data

a. Occupation code

OWCP Use - NOI Code

b. Type code c. Source code

Employee Signature

Claim Information

City State ZIP Code

City State ZIP Code

1a. Email Address

U.S. Department of Labor

Office of Workers' Compensation Programs
Official Supervisor's Report of Occupational Disease: Please complete information requested below

19. Agency name and address of reporting office (include street address, city, state, and ZIP Code) OWCP Agency Code

OSHA Site Code

City State ZIP Code

20. Employee's duty station (include street address, city, state, and ZIP code) City State ZIP Code

21. Regular 22. Regular

work a.m. a.m. work

hours From: p.m. To: p.m. schedule Sun. Mon. Tues. Wed. Thurs. Fri. Sat.

26. Date employee 27. Date and a.m. first reported hour employee

stopped work Time p.m. condition to

supervisor

28. Date and 29. Date employee was last a.m. hour employee's exposed to conditions

pay stopped Time p.m. alleged to have caused

disease or illness

30. Date a.m. returned

to work Time p.m.

31. If employee has returned to work and work assignment has changed, describe new duties

 32. Employee's Retirement Coverage CSRS FERS Other, (Specify)

33. Was injury caused

by third party?

Yes No

If "No",

go to

Item 35.

35. A supervisor who knowingly certifies to any false statement, misrepresentation, concealment of fact, etc., in respect to this claim

may also be subject to appropriate felony criminal prosecution.

I certify that the information given above and that furnished by the employee on the reverse of this form is true to the best of my

knowledge with the following exception:

Name of Supervisor (Type or print)

Signature of Supervisor Date

Supervisor's Title Office phone

Form CA-2

Rev. October 2018

Supervisor's Report

Signature of Supervisor

23. Name and address of physician first providing medical care (include city, state, ZIP code) 24. First date Mo. Day Yr

medical

care received

25. Do medical reports

show employee is Yes No

disabled for work?

34. Name and address of third party (include street address, city, state, and ZIP code)

City State ZIP Code

City State ZIP Code

Mo. Day Yr Mo. Day Yr

Mo. Day Yr Mo. Day Yr

Mo. Day Yr

Page 2
The FECA, which is administered by the Office of Workers'

Compensation Programs (OWCP), provides the following

general benefits for employment-related occupational disease

or illness:

The first three days in a non-pay status are waiting days, and

no compensation is paid for these days unless the period of

disability exceeds 14 calendar days, or the employee has

suffered a permanent disability. Compensation for total

disability is generally paid at the rate of 2/3 of an employee's

salary if there are no dependents, or 3/4 of salary if there are

one or more dependents.

(1) Full medical care from either Federal medical officers and

hospitals, or private hospitals or physicians of the

employee's choice.

An employee may use sick or annual leave rather than LWOP

while disabled. The employee may repurchase leave used

for approved periods. Form CA-7b, available from the

personnel office, should be studied BEFORE a decision is

made to use leave.

(2) Payment of compensation for total or partial wage loss.

(3) Payment of compensation for permanent impairment of

certain organs, members, or functions of the body (such as

loss or loss of use of an arm or kidney, loss of vision, etc.),

or for serious disfigurement of the head, face, or neck. If an employee is in doubt about compensation benefits, the

OWCP District Office servicing the employing agency should

be contacted. (Obtain the address from your employing

agency.)

(4) Vocational rehabilitation and related services where

necessary.

For additional information, review the regulations governing the

administration of the FECA (Code of Federal Regulations, Title

20, Chapter 1) or Chapter 810 of the Office of Personnel

Management's Federal Personnel Manual.

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'

Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation

Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)

Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be

verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the

claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to

consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other

government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services.

(5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational

rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be

given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to

determine whether benefits are being paid properly, including whether prohibited dual Payments are being made, and, where appropriate, to

pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7)

Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and

other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal

government, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing

of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the

processing and adjudication of the claim you filed under the FECA.

This acknowledges receipt of notice of disease or illness sustained by:

(Name of injured employee)

I was first notified about this condition on (Mo., Day, Yr.)

At (Location)

Title Date (Mo., Day, Yr.) Signature of Official Superior

This receipt should be retained by the employee as a record that notice was filed.

Form CA-2

Disability Benefits for Employees under the Federal Employees' Compensation Act (FECA)

Privacy Act

Receipt of Notice of Occupational Disease or Illness

Rev. October 2018

Page 3
INSTRUCTIONS 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.

Complete items 1 through 18 and submit the form to the employee's supervisor along with the statement and medical reports described below.

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

a) Dates of examination or treatment.

1) Employee's statement

In a separate narrative statement attached to the form, the

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.

c) Detailed description of the physician's findings.

d) Results of x-rays, laboratory tests, etc.

started.

b) Complete details of the conditions of employment which are

believed to be responsible for the disease or illness.

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

the number of hours per day and days per week of such

exposure or stress.

f) Clinical course of treatment.

g) Physician's opinion as to whether the disease or illness

was caused or aggravated by the employment, along with

an explanation of the basis for this opinion. (Medical

reports that do not explain the basis for the physician's

opinion are given very little weight in adjudicating the

claim.)

d) Identification of the part of the body affected. (If disability

is due to a heart condition, give complete details of all

activities for one week prior to the attack with particular

attention to the final 24 hours of such period.)

e) A statement as to whether the employee ever suffered a

similar condition. if so, provide full details of onset,

history, and medical care received, along with names and

addresses of physicians rendering treatment.

3) Wage loss

If you have lost wages or used leave for this illness, Form

CA-7 should also be submitted.

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:

a) Describe in detail the work performed by the employee. c) Attach a record of the employee's absence from work caused

by any similar disease or illness. Have the employee state the

reason for each absence.

Identify fumes, chemicals, or other irritants or situations

that the employee was exposed to which allegedly caused

the condition. State the nature, extent, and duration of the

exposure, including hours per days and days per week,

requested above.

d) Attach statements from each co-worker who has first-hand

knowledge about the employee's condition and its cause. (The

co-workers should state how such knowledge was obtained.)

b) Attach copies of all medical reports (including x-ray reports

and laboratory data) on file for the employee. e) Review and comment on the accuracy of the employee's statement requested above.

The supervisor should also submit any other information or evidence pertinent to the merits of this claim.

24. First date medical care received

The date of the first visit to the physician listed in item 23.

14. Nature of the disease or illness

Give a complete description of the disease or illness. Specify

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

from OWCP should be sent (if applicable, the address of the

personnel or compensation office).

Indicate which retirement system the employee is covered

under.

33. Was the injury caused by third party?

A third party is an individual or organization (other than the

injured employee or the Federal government) who is liable for

the disease. For instance, manufacturer of a chemical to which

an employee was exposed might be considered a third party if

improper instructions were given by the manufacturer for use of

the chemical.

Employee (or person acting on the Employee's behalf)

Item Explanation: Some of the items on the form which may require further clarification are explained below.

Supervisor (Or appropriate official in the employing agency)

23. Name and address of physician first providing

medical care

The name and address of the physician who first provided

medical care for this injury. If initial care was given by a

nurse or other health professional (not a physician) in the

employing agency's health unit or clinic, indicate this on a

separate sheet of paper.

Form CA-2

Rev. Oct. 2018

Page 4

1a. Email Address

Injured workers should provide an email address when completing 

this form. Pursuant to policy established by the Department of Labor, 

Office of Workers' Compensation Programs (OWCP), Division of 

Federal Employees' Compensation, email communication on case 

specific inquiries is not allowed due to security concerns. However, 

obtaining claimant email addresses at the point of filing will allow 

OWCP to share general, non-case specific information with injured 

workers earlier in the claims submission process. As a longstanding 

policy and in an effort to protect the identities and personal 

information of claimants under the Federal Employees' 

Compensation Act, and to allow better tracking of incoming 

communications, we do not use two-way email as a primary method 

of interaction with claimants and their representatives.
OWCP Agency Code

This is a four digit (or four digit two letter) code used by OWCP

to identify the employing agency. The proper code may be obtained

from your personnel or compensation office, or by contacting OWCP.

Box a (Occupational Code), Box b. (Type Code), Box c

(Source Code), OSHA Site Code

The Occupational Safety and Health Administration (OSHA)

requires all employing agencies to complete these items when

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. Oct. 2018

Employing Agency - Required Codes

INSTRUCTIONS FOR COMPLETING FORM CA-2 Continued

Page 5