Official Superior’s Report of

Employee’s Death

1. Name of Deceased Employee (Last, first. middle)

5. Department or Agency

U.S. Department of Labor

I

*

Office of Workers’ Compensation Programs *

2. Date of Birth (MO., day, year) 3.

0 Transgender

/ 4. Social Security NO,

0

 Female

6. OWCP Agency Code 7. OSHA Site Code

8. Name and Address of Reporting Office 9. Name and Office Phone Number of Employee’s Official Superior

I

10. Date and Hour of Injury

(MO., day, year)

0 AM

cl PM

13. Describe how injury occurred

11. Date and Hour of Death

(MO., day, year)

0 AM

0 PM

14. Was employee in perfo

12. Date and Hour Employee’s Pay Stopped

(MO., day, year)

c] AM

0 PM

rmance of duty when injury occurred?

0 Yes 0 No (if No, explain) :

15. Location where Injury occurred 16. Location where death occurred 17. lmmediate cause of death (Attach medical

18. Employee’s pay rate as of

A. Date of injury

B. Date pay stopped

19. Did employee work in positron held at tim

a. Base pay

$ per

$ per

of injury

for a full eleven months immediately prior to the injury?

0 yes 0 No

and autopsy report if available)

b. Subsistence c. Quarters d. Other

$ per S per $ per

S per S per S per

20. If answer to 19 is no, would position have afforded employment

for eleven months except for the injury?

0 Yes ci No

21. Did employee receive leave pay for any part of period from time pay stopped to

date of death? (Give inclusive dates)

22. a. Occupation code

From To

23. Did employee receive continuation of pay (COP) during perrod pnor to death?

b. Type code

OWCP use - NOI code

c. Source code

a. Pay rate used for COP

$ per

i b. Inclusive dates of cop

From To

24. If employee was enrolled in Health

Benefit Plan for self and family, show

HBS Code Number:

25. Show date through which HBS deductions

were last made (MO., day, year)

28. If injury was caused by a third party, give

name and address of third party

31. If employee was a member of the Armed Services

Branch of Service:

Serial No. (If known)

I

26. ldentify employee’s Federal Retirement Plan: 27. If employee received medical care prior

0 CSBS 0 FERS 0 Other

to death, give name and address of

attending physician

29. Give name and address of the attorney representing the

survivors if legal action is instituted against the third party /

I $

 the United States, show: 1 32. Has claim for survivor’s

I

benefits been filed with the

Office of Personnel Management?

0 Yes 0 No

33. Name and address of employee’s spouse or next of kin (Show relationship, if other than spouse)

34. Signature of Official Superior 35. Title / 36. Date (MO., day, year)

Form CA-6

Rev. Jan. 1997

Gender

 Male

Non-Binary
Instructions for Completing Form CA-6

When a Federal employee dies as a result of injury in performance of duty or because of an

employment related disease, the death should be reported on this form. This form eliminates

the need to complete and file the official superior’s report on Form CA-l, Federal Employee’s

Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation or Form CA-2,

Federal Employee’s Notice of Occupational Disease and Claim for Compensation.

The form is to be completed by the deceased employee’s official superior or other authorized

official of the employing agency. It should be accompanied by a certified copy of the death

certificate. when submitted to OWCP.

Form CA-5 or CA-5b should be supplied to the employee’s spouse or next of kin.

If additional space is required, attach separate sheets and number the answers to correspond

with the items on the form.

For additional information about death benefits, see 20 CFR 1.1 and/or Chapter 810, Injury

Compensation, Federal Personnel Manual.

Box 22a (Occupation Code), Box 22b (Type Code),

Box 22c (Source Code), OSHA She 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, Recordkeeping and Reporting Guidelines.

OWCP Agency Code

This is a four digit (or four digit plus 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.