U.S. Department of Labor

Office of Workers' Compensation Programs Evidence Required in Support of a Claim

for Occupational Disease

All of the following information should be submitted with Form CA-2. Please return the checklist with your statements attached. Check off each

item as it is completed or let us know when we can expect the information. All material submitted should be legible and specific.

FROM EMPLOYEE

1. Give a detailed description of factors of

employment believed responsible for

condition. Be specific as to the duration

and nature of the factors: for instance

weights carried, distances walked, chemicals used, or other relevant job actions.

2. Give the history of the condition from

first awareness of the problem. Include

description of all home treatment and

professional care as well as symptoms.

3. Describe any prior similar problem, with 8. Attach copies of the employee's:

dates of onset, history, medical care

received, and copies of the medical

records of your treatment. a. SF-171, Application for Employment.

b. Position description with physical

4. Attach or forward a medical report from requirements.

your physician to include the following

items: c. Pertinent dispensary records.

a. Dates of examination and treatment. d. Most recent SF-50, Notification of

Personnel Action.

b. History given by you.

c. Detailed description of findings.

d. Results of all diagnostic tests.

e. Diagnosis.

f. The clinical course of treatment

followed.

g. Doctor's opinion, with reasons for

such opinion, as to the relationship

between any condition you may now

have and the factors of employment

identified in Item no. 1 above.

Form CA-35A

Rev. Aug.1988

P FROM EMPLOYING AGENCY P

5. Review and comment on employee's

statement provided in response to Item

no. 1.

6. If employee's job differs from official

description, describe exactly his/her

duties.

7. Give a day-by-day listing of leave and

leave without pay used due to this

condition.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'

Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or

aggravated the disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial

effort. The attached checklist is designed to help you. Form CA-2 ("Federal Employees' Notice of Occupational Disease and

Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be

given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off

each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation

Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your

Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information

directly to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post

card advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for

the same period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your

statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR

PHYSICIAN IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists to help you and the employee submit a claim in an organized and complete manner. The checklists will help the

claims examiner identity what information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and

2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to

mark and return with the completed package. The second checklist is for the employee to take to the physician.

In addition to describing the evidence required from the employee, the checklists describe the information to be submitted

by the employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions

on the CA-2 to forward them to OWCP within ten working days. Statements and documents required from the agency

should be submitted with the CA-2 whenever possible. Please use the checklist to note what information from the

employing agency is enclosed, unavailable or pending. If pending, please give the anticipated mailing date. Agency

comments, statements and documentation are essential for the examiner to get a well rounded picture of the

employment conditions.

We appreciate your cooperation in this effort.
U.S. Department of Labor

Office of Workers' Compensation Programs

Evidence Required in Support of a

Claim for Work-Related Hearing Loss

IF YOU ARE FILING A CLAIM FOR HEARING LOSS, THIS CHECKLIST DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR

EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2. Please return the checklist with your

statements attached. Check off each item as it is completed or let us know when we can expect the information. All material submitted

should be legible and specific.

FROM EMPLOYEE

1. List your employment history by employer, job title, and inclusive dates.

Include non-Federal employment and

military service. 10. Describe all work-related exposure to

hazardous noise, including:

2. For each job title, describe source of a. Locations of job sites. noise, number of hours of exposure per

day, and use of any safety devices to

protect against noise exposure. State

when safety devices were provided.

b. Nature of exposure to noise

(machinery, etc.).

c. Decibel and frequency level (noise

survey report) for each job site.

d. Period of exposure, hours per day,

days per week.

e. Type of ear protection provided.

Attach copies of the employee's:

a. SF-171, Application for Employment.

b. Job sheet and employment record.

c. All medical examinations pertaining

7. State whether a claim for workers, to hearing or ear problems, including

preemployment examination and all

audiograms.

compensation benefits for this or any

other condition affecting ears or hearing

was ever filed. If so, give date of claim,

name and address where filed, and

benefits received. 12. If the employee is no longer exposed to

hazardous noise, give date of last

exposure and the payrate in effect on

that date.

Form CA-35B

Rev. Aug. 1988

11.

P FROM EMPLOYING AGENCY P

Review and comment on the employee's

statement in response to questions 1-5.

9.

3. Give history of any previous ear or hearing

problems.

4. Describe any hobbies which involve

exposure to loud noise.

5. If you are no longer exposed to hazardous

noise at work, give the date you were last

exposed.

6. If you have been examined or treated by

a doctor for an ear or hearing problem,

provide a medical report and audiograms.

8. Give the date you first noticed your hearing

loss.

Give date you first related hearing loss to

employment, and reason why.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'

Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or

aggravated the disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial

effort. The attached checklist is designed to help you. Form CA-2 ("Federal Employees' Notice of Occupational Disease and

Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be

given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off

each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation

Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your

Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information

directly to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post

card advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management (OPM) and workers' compensatiion benefits from OWCP. However, in most cases, you cannot receive both benefits for

the same period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your

statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN

IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists to help you and the employee submit a claim in an organized and complete manner. The checklists will help the

claims examiner identify what information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees Notice of Occupational Disease and Claim for Comeprisation, and

2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to

mark and return with the completed package. The second checklist is for the employee to take to the physician.

In addition to describing the evidence from the employee, the checklists describe the information to be submitted by the

employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the

CA-2 to forward them to OWCP within ten working days. Statements and documents required from the agency should be

submitted with the CA-2 whenever possible. Please use the checklist to note what information from the employing agency

is enclosed, unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements

and documentation are essential for the examiner to get a well rounded picture of the employment conditions.

We appreciate your cooperation in this effort.
U.S. Department of Labor

Office of Workers' Compensation Programs

Evidence Required in Support of A

Claim for Asbestos-Related Illness

If you are filing a claim based on exposure to asbestos. Use this checklist to identify the information needed from you and your employing agency. All of the following information should be submitted with Form CA-2. Please return the checklist with your statements attached.

Check off each item as it is completed or let us know when we can expect the information. All material submitted should be legible and specific.

2. For each job title, describe the work you performed, the 10. Provide exposure data, including air sample surveys or

statements of the type of asbestos exposure, frequency,

degree and duration for each job held. Air sample

results should be reported in units of fiber/cc time

weighted average. Also report concentrations of other

pollutants and chemicals (see attached questionnaire).

type of asbestos material used, locations where exposure

occurred, period of exposure, number of hours per day

and days per week exposed, and the types and frequency

of safety precautions (mask, respirator, etc.) used (see

attached questionnaire).

11. Give the date employee was last exposed to asbestos

at work. If the employee was removed from exposure,

give the circumstances.

12. Attach copies of the employee's:

a. SF-1 71, Application for Employment.

b. Position description with physical requirements

for last job hold.

6. Submit a report from your physician, including chest x-ray

report, history, physical findings, diagnosis, opinion as to

the relationship of the condition to employment, and course

of treatment.

c. Job sheet and employment record.

d. Pertinent dispensary records.

e. Most recent SF-50, Notification of Personnel

Action.

f. Laboratory test results and chest x-ray reports

on file.

13. Describe safety regulations and protective devices in

use by employee, with period and frequency of use.

Form CA-35C

Oct. 1987

FROM EMPLOYEE P P

1. List your employment history by employer, job title, and

inclusive dates. Include non-Federal employment and

military service (see attached questionnaire.)

FROM EMPLOYING AGENCY

Review and comment on the accuracy of the employee's

description of work performed and exposure to asbestos

and other substances.

9.

3. Describe any exposure you have had to other toxic sub-

 stances. If none, state "None".

4. Describe any breathing or lung problems you have had in the

past and treatment received (see attached questionnaire).

5. Give your smoking history to include amount per day, and

years (dates) you have smoked (see attached questionnaire).

7. Give the date you first consulted a physician regarding respiratory or asbestos-related disease.

8. Submit reports of examination, treatment or hospitalization

for any previous similar condition or pulmonary problem.
PART A TO BE COMPLETED BY CLAIMANT

In order to determine if you are eligible for benefits, please provide the following information using your best estimates. If you run out of space, use

a separate piece of paper and attach it to this form. Submit the form to your current (or last) employing agency. If the facility is no longer active,

submit the statement to OWCP.

I. Employment History: Please include all employers, both Federal and non-Federal, your job titles, the work you performed, and the period

you held each job. (Include military service).

II. Exposure History: Please describe all exposure to asbestos and other toxic materials in your employment. Include period of employment,

type of exposure, number of hours exposed per workday and description of safety precautions used while working.

a. Asbestos: For "type of exposure" indicate whether exposure was heavy, medium or light:

Heavy - Visible airborne asbestos particles were evident.

Medium - Asbestos dust was visible on floors and work surfaces.

Light - No dust visible, but asbestos was in use.

b. Toxic Chemicals/Dust

(PLEASE CONTINUE ON REVERSE SIDE)

1.

Employer (Agency) Job Title Work Performed Period Fed. Civil Service? (Yes/No)

1 .

2.

3.

4.

5.

6.

7.

8.

Period Type of Exposure (H, M, L) Exposure Hrs/Day Safety Precautions Used

1 .

2.

3.

4.

5.

Period Material Exposed to: Exposure Hrs/Day Safety Precautions Used

2.

3.

4.

5.
Notice to Employees Filing Claim for Occupational Disease

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal

Employees' Compensation Act. You must provide factual and medical evidence to establish that conditions of employment

caused or aggravated the disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial

effort. The attached checklist is designed to help you. Form CA-2 ("Federal Employee's Notice of Occupational Disease and

Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be

given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off

each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation

Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your

agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information directly

to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post

card advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel

Management (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits

for the same period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your

statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN

IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

Notice to Compensation Specialists and Supervisors

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists

to help you and the employee submit a claim in an organized and complete manner. The checklists will help the claims

examiner identify what information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and

2. Two copies of the checklist describing evidence required-in support of the claim. One checklist is for the employee to mark

and return with the complete package. The second checklist is for the employee to take to the physician.

In addition to describing the evidence required from the employee, the checklists describe the information to be submitted by the

employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2

to forward them to OWCP within ten working days. Statements and documents required from the agency should be submitted

with the CA-2 whenever possible. Please use the checklist to note what information from the employing agency is enclosed,

unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements and documentation

are essential for the examiner to get a well rounded picture of the employment conditions.

We appreciate your cooperation in this effort.
Ill. Medical History: Describe your medical history and include any treatment for heart, lung and other major health problems.

IV. Smoking History: Describe your smoking history, including dates you smoked, amount of material smoked per day, and type of material

smoked.

PART B TO BE COMPLETED BY EMPLOYING AGENCY

Using the categories shown below, please complete the chart at the bottom of the page with reference to each Federal job hold by this employee.

a. Nature of Exposure:

Primary - Normal duties required actual manipulation of asbestos and/or asbestos-related products and generated dust.

Secondary - Normal duties regularly involved work alongside others primarily exposed or in confined spaces.

Intermittent - Normal duties irregularly involved entry into locations where asbestos and/or asbestos products were manipulated.

Environmental - Normal duties were performed at a location where asbestos was used but the individual had no normal exposure in excess

of ambient levels.

b. Degree of Exposure:

Heavy - Asbestos dust was usually visible in the air.

Medium - Asbestos dust was generally visible on work surfaces but did not cloud the air.

Light - Asbestos was used in work area but was generally not visible (although detectable).

Ambient - Asbestos levels did not exceed normal levels In the air outside of work spaces.

c. Frequency of Exposure: Hours per day.

Job Title Period Asbestos Exposure Other Chemical or Dust Exposure

From To Nature Degree Frequency Material Nature Degree Frequency Fiber/cc

*U.S. Government Printing Office: 1989-229-460/99190

Have you ever had: Yes No If Yes, explain Dates

1. Heart Problems?

2. Lung Problems?

3. Other Major

Problems?

Have you ever smoked: Yes No If Yes, amount No. of years Date stopped Dates

1. Cigarettes?

2. Pipe?

3. Cigars?

1.

2.

3.

4.

5.

6.

7.

8.
U.S. Department of Labor

Office of Workers' Compensation Programs

Evidence Required in Support of a Claim

for Work-Related Coronary/Vascular Condition

IF YOU ARE FILING A CLAIM FOR CORONARY OR VASCULAR CONDITIONS (for example: heart attack, stroke, hypertension). THIS CHECKLIST

DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR EMPLOYING AGENCY. All of the following information should be submitted

with Form CA-2. Please return the checklist with your statements attached. Check off each item as it is completed or let us know when we

can expect the information. All material submitted should be legible and specific.

FROM EMPLOYEE

1. Give a detailed description of the factors

of your employment you believe responsible for your condition. Identify dates,

periods, events, people involved, etc. 7. Describe in detail the duties of the

employee and the manner in which the

duties were performed. If the work was

different or more stressful than that performed by other employees, this should

be explained.

2. If you are claiming compensation for a

heart attack or stroke, provide a specific

account of your activities on and off duty

for one week prior to the attack, with

emphasis on the twenty-four hours immediately preceding the attack. 8. Document any personnel actions descried in the employee's statement, such as

changes in assignment, grievances filed by

the employee, and other adverse personnel actions.

3. If you have a prior history of heart problems, provide a description of your condition and copies of medical records of

treatment.

4. Give your smoking history to include

amounts and years (dates) you smoked.

5. Provide a medical report from your

physician which includes:

a. Dates of examination and treatment. 11. Attach copies of the employee's:

b. History given by you. a. SF-171, Application for Employment.

c. Family history and other risk factors.

d. Detailed description of findings.

e. Copies of all diagnostic test results.

f. Diagnosis.

b. Position description with physical

requirements.

c. Preemployment medical examination.

d. All other pertinent medical reports

available.

g. The clinical course of treatment

followed.

e. Most recent SF-50, Notification of

Personnel Action.

Doctor's opinion, with reasons for

such opinion, as to the relationship

between any condition you may now

have and the factors of employment

identified in Item no. 1 above.

h.

Form CA-35D

Rev. Aug. 1988

P FROM EMPLOYING AGENCY P

6. Review and comment on the employee's

statements in response to questions 1-5.

9. Give the number of hours worked per

day, days per week and the extent of

overtime duty worked.

10. Provide a day-by-day listing of leave and

leave without pay used due to this condition.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'

Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or

aggravated the disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial

effort. The attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and

Claim for Compensation''), your statements in response to the checklist, and a report from your treating physician should all be

given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off

each item as it is completed to let us know when we can expect the information. Your supervisor and the Compensation

Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your

Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information

directly to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post

card advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for

the same period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your

statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR

PHYSICIAN IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists to help you and the employee submit a claim in an organized and complete manner. The checklists will help the

claims examiner identify what information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and

2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to

mark and return with the completed package. The second checklist is for the employee to take to the physician.

In addition to describing the evidence required from the employee, the checklists describe the information to be submitted

by the employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions

on the CA-2 to forward them to OWCP within ten working days. Statements and documents required from the agency

should be submitted with the CA-2 whenever possible. Please use the checklist to note what information from the

employing agency is enclosed, unavailable or pending. If pending, please give the anticipated mailing date. Agency

comments, statements, and documentation are essential for the examiner to get a well rounded picture of the

employment conditions.

We appreciate your cooperation in this effort.
Evidence Required in Support of a Claim

for Work-Related Skin Disease

U.S. Department of Labor

Office of Workers' Compensation Programs

IF YOU ARE FILING A CLAIM FOR A SKIN CONDITION, THIS CHECKLIST DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR

EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2. Please return the checklist with your

statements attached. Check off each item as it is completed or let us know when we can expect the information. All material submitted

should be legible and specific.

FROM EMPLOYEE FROM EMPLOYING AGENCY

1. Give a detailed description of employ- 6. Review and comment on the employee's

ment factors you believe responsible for

your condition, to include:

statements provided in response to questions 1-5. Comment on the exposure

claimed, providing any available informaa. Specific type of exposure. tion about the trade name and/or chemical content of the suspected irritants.

b. Frequency and duration of exposure.

7. Provide a day-by-day listing of leave and

c. Protective equipment used to guard leave without pay used due to this condiagainst exposure. tion.

8. Attach copies of the employee's: 2. Describe any exposure to skin irritants

outside the work environment, including

the type, duration and frequency of

exposure.

a. SF-171, Application for Employment.

b. Position description with physical requirements.

c. Pertinent dispensary records.

d. Copies of all physical examinations on

file.

e. Most recent SF-50, Notification of

Personnel Action.

5. Attach or forward a medical report from

your current physician to include:

a. History of exposure.

b. Findings.

c. Diagnosis.

d. Details of treatment.

e. Explanation of the relationship

between the findings and exposure

history listed in Item no. 1 above.

 f. Discussion of temporary vs. permanent effect from work exposure.

g. Work restrictions caused by the

condition.

Form CA-35E

Rev. Aug. 1988

P P

3. Describe any previous skin conditions

from the time they began through the

present.

4. Provide treatment records from any

physicians who have provided treatment

for any skin conditions.
Evidence Required in Support of a Claim

 for Work-Related Pulmonary Illness

U.S. Department of Labor

Office of Workers' Compensation Programs

(not asbestosis)

IF YOU ARE FILING A CLAIM FOR PULMONARY CONDITION NOT RELATED TO EXPOSURE TO ASBESTOS, THIS CHECKLIST DESCRIBES THE

INFORMATION NEEDED FROM YOU AND YOUR EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2.

Please return the checklist with your statements attached. Check off each item as it is completed or let us know when we can expect the

information. All material submitted should be legible and specific.

FROM EMPLOYEE FROM EMPLOYING AGENCY

1. Describe the work conditions which 6. Review and comment on employee's

caused or aggravated your pulmonary

condition; include types of irritants, dates

of exposure and hours per day. Describe

any safety measures taken.

statement provided in response to

questions 1-5. Give periods, degree

and nature of exposure. Explain safety

precautions. Give full details of any

tests which were made to determine

the concentration of irritants. Have

other employees been similarly

affected?

2. Explain the development of the present

pulmonary condition and treatment from

its beginning.

7. Provide a day-by-day listing of leave

and leave without pay used due to this

condition.

3. Give your smoking history to include

amounts and years (dates) you smoked.

8. Attach copies of the employee's: 4. Give the history of previous pulmonary

conditions: include dates and nature of

illness, and treatment records from all

physicians and hospitals where you were

treated.

a. SF-171, Application for Employment.

b. Position description with physical

requirements.

5. Attach or forward a medical report

which includes the following items:

c. Preemployment medical examination

and any other pertinent medical

records.

a. Dates of examination and treatment. d. Most recent SF-50, Notification of

Personnel Action.

b. History given by you.

c. Detailed description of findings.

d. Results of all diagnostic tests.

e. Diagnosis.

f. The clinical course of treatment

followed.

g. Doctor's opinion, with reasons for

such opinion, as to the relationship

between any condition you may

have and the factors of employment

listed in Item no. 1.

Form CA-35F

Rev. Aug. 1988

P P
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'

Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or

aggravated the disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial

effort. The attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and

Claim for Compensation''), your statements in response to the checklist, and a report from your treating physician should all be

given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off

each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation

Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your

Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information directly

to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post

card advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management (OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for the

same period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your

statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN IS

REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists

to help you and the employee submit a claim in an organized and complete manner. The checklists will help the claims examiner

identify what information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2. Federal Employees Notice of Occupational Disease and Claim for Compensation, and

2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to

mark and return with the completed package. The second checklist is for the employee to take to the physician.

In addition to describing the evidence from the employee, the checklists describe the information to be submitted to by the

employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2 to

forward them to OWCP within ten working days. Statements and documents required from the agency should be submitted with

the CA-2 whenever possible. Please use the checklist to note what information from the employing agency is enclosed,

unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements and documentation

are essential for the examiner to get a well rounded picture of the employment conditions.

We appreciate your cooperation in this effort.
Evidence Required in Support of a Claim

for Work-Related Psychiatric Illness

U.S. Department of Labor

Office of Workers' Compensation Programs

IF YOU ARE FILING A CLAIM FOR A PSYCHIATRIC CONDITION, THIS CHECKLIST DESCRIBES THE INFORMATION NEEDED FROM YOU AND YOUR

EMPLOYING AGENCY. All of the following information should be submitted with Form CA-2. Please return the checklist with your

statements attached. Check off each item as it is completed or let us know when we can expect the information. All material submitted

should be legible and specific.

FROM EMPLOYEE FROM EMPLOYING AGENCY

1. Give a detailed chronological description 7. Review and comment on the employee's

of particular employment factors which

you believe caused your condition. Please

identify dates, periods, events, people

involved, etc.

statements provided in response to

questions 1-5. Submit statements from

witnesses, if appropriate.

8. Provide a detailed statement describing

2. Describe the progress and development

of the work-related condition from its

beginning.

the duties of the employee and the

manner in which the duties were

performed. If the work was different or

more stressful than that performed by

other employees, this should be

explained.

3. Have you previously suffered from this

or a similar condition? If so, give details

of symptoms, disability and treatment

records from all physicians and

hospitals where you were treated.

9. Document any personnel actions

described in the employee's statement,

such as changes in assignment,

grievances filed by the employee, and

other adverse personnel actions.

10. Give the number of hours worked per

day, days per week and the extent of

overtime duty worked.

 11. Provide a day-by-day listing of leave

and leave without pay used due to this

condition.

12. Attach copies of the employee's:

a. SF-171, Application for Employment.

b. Position description with physical requirements.

c. Preemployment medical examination.

d. All other pertinent medical reports

available.

e. Most recent SF-50, Notification of

Personnel Action.

Form CA-35G

Rev. Aug. 1988

P P

4. Give a brief description of your personal

activities, hobbies, and any other employment.

5. Describe changes or other sources of

stress in your personal life occurring in the

same time frame.

6. Attach or forward a medical report as

described on the reverse.
MEDICAL REPORT FOR PSYCHIATRIC CLAIM

You should submit a medical report from your physician which includes:

a. History of onset of illness.

b. Social and family history.

c. Detailed description of your work situation and identification of the specific work factors contributing to your emotional or psychiatric

condition.

d. Review of any non-industrial stress situations.

e. Mental status examination, with pertinent findings.

f. Results of psychological and personality testing.

g. Diagnosis according to DSM III.

h. Clinical course of treatment followed.

i. Prognosis with estimate of when you will be able to return to work.

j. Physician's opinion, with reasons for such opinion, as to whether, how and which factors of your employment caused,

aggravated, precipitated, or accelerated your disability.

k. An assessment of your current condition, with specific details on how you can or cannot function in daily activities, including a

discussion of any limitations you may have in your ability to give or take supervision, cooperate with others, work under deadlines,

or any other pertinent factors which may effect your work capacity.

NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'

Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or aggravated the

disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial effort. The

attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and Claim for

Compensation''), your statements in response to the checklist, and a report from your treating physician should all be given to your agency

Compensation Specialist at the same time. Please return the checklist with your statements. Check off each item as it is completed or let us

know when we can expect the information. Your supervisor and the Compensation Specialist will compile the additional information

required and forward a complete and organized package to OWCP. If your Agency has no Compensation Specialist or other person

designated to forward information to OWCP, give the information directly to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post card

advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management (OPM)

and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for the same period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your statements

answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN IS REQUIRED. Reports

on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists to help you

and the employee submit a claim in an organized and complete manner. The checklists will help the claims examiner identify what

information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and

2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to mark and return

with the completed package. The second checklist is for the employee to take to the physician.

In addition, to describing the evidence required from the employee, the checklists describe the information to be submitted by the

employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2 to forward

them to OWCP within ten working days. Statements and documents required from the agency should be submitted with the CA-2 whenever

possible. Please use the checklist to note what information from the employing agency is enclosed, unavailable or pending. If pending,

please give the anticipated mailing date. Agency comments, statements and documentation are essential for the examiner to get a well

rounded picture of the employment conditions.

We appreciate your cooperation in this effort.
U.S. Department of Labor

Office of Workers' Compensation Programs

Evidence Required in Support of A Claim

for Work-Related Carpal Tunnel Syndrome

If you are claiming that your carpal tunnel or wrist problems are due to your job, use this checklist to identify the specific

information needed from you and your employing agency to make a decision on the claim. All of the following information should be

submitted with Form CA-2. Please return the checklist with statements attached. Check off each item as it is completed or let us know when we

can expect the information. All material submitted should be legible and specific.

FROM EMPLOYEE

1. Prepare a statement giving the following information:

a. Provide an outline of your work history, including nonFederal employment and military service. For each job held,

give your job title, agency/company name, and dates (period)

of employment.

b. For each job title, describe duties which required

exertion with or repeated movement of the wrist or hand.

Describe nature and frequency of motions required, and

average number of hours a day/week you did such work.

c. Give date employee entered on duty in job requiring

above duties. Also give the effective date(s) and description(s) of any changes in work assignments due to

employee's condition and indicate whether duty changes

resulted in changes in pay.

c. Describe hobbies, physical fitness or other activities

outside of work which also involved exertion or repeated

motions of wrist/hand. State the nature of each such activity,

years involved in each, and how many hours a week you

engaged in such.

d. If you have ever had an injury to the hand/arm/wrist,

or been diagnosed as having gout, arthritis, hypothyroidism,

diabetes, a tumor, or deformity of the hand/wrist, from/since

birth, describe the injury or condition, and state when injury

occurred or condition was found.

2. Send us copies of employee's:

a. SF-1 71, Application for Employment;

b. Position description with physical requirements

for last job held; e. Give a brief chronological history of your hand/wrist

problem. State which hand(s) are affected, when you first

experienced problems, nature of the problems and changes

over time to present, and dates and nature of medical care

obtained. c. All available medical records, including report of

pre-employment examination;

d. SF-50s or equivalent documents for changes in

assignment/pay due to condition.

2. Ask all doctors who treated you to send us a copy of reports or notes describing the condition, testing, and treatment

given.

3. Ask the doctor currently treating your condition to provide a detailed current medical report to include the following specifics:

a. Dates of examinations; e. Treatment to date and prognosis;

f. Reasoned opinion expIaining any causal relationship

between the condition and your Federal civilian job.

b. Complete medical history of condition;

c. Medical diagnosis of condition;

It is MOST IMPORTANT that the doctor provide opinion as

to the likely nature of the physical effects attributable to

specified duties of your Federal job, and explain the medical

reasoning which supports the opinion as to cause.

d. Findings and test results, specifically including:

results of Phalen's and Tinel's Sign tests: physical

findings concerning sensation over palmar aspect

of first three and one-half digits, and dorsal aspect

of end joints of same digits, and any atrophy of the

Thenar Eminence; results of nerve conduction velocity,

and electromyographic testing;

For sale by the Superintendent of Documents, U.S. Government Printing Office. Washington. D.C. 20402 Form CA-35H

October 1987

P FROM EMPLOYING AGENCY P

1. Review the employee's statement, giving the following

information:

a. Comment on the accuracy of the employee's statement describing Federal job duties involving use of hand/

wrist.

b. Provide a day-to-day listing of leave and leave without pay used by the employee due to carpal tunnel/wrist

problems.
NOTICE TO EMPLOYEES FILING CLAIM FOR OCCUPATIONAL DISEASE

Diseases and illnesses which occur during or after Federal employment are not automatically covered by the Federal Employees'

Compensation Act. You must provide factual and medical evidence to establish that conditions of employment caused or

aggravated the disease or illness.

The Office of Workers' Compensation Programs (OWCP) understands that gathering the necessary evidence requires substantial

effort. The attached checklist is designed to help you. Form CA-2 (''Federal Employees' Notice of Occupational Disease and

Claim for Compensation"), your statements in response to the checklist, and a report from your treating physician should all be

given to your agency Compensation Specialist at the same time. Please return the checklist with your statements. Check off

each item as it is completed or let us know when we can expect the information. Your supervisor and the Compensation

Specialist will compile the additional information required and forward a complete and organized package to OWCP. If your

Agency has no Compensation Specialist or other person designated to forward information to OWCP, give the information directly

to your supervisor.

Upon receipt of your claim, OWCP will create a case and assign it to a claims examiner for processing. You will receive a post

card advising you of the case number. Use this number on all future correspondence about your claim.

If you are eligible for Civil Service retirement, you may apply for both retirement benefits from the Office of Personnel Management

(OPM) and workers' compensation benefits from OWCP. However, in most cases, you cannot receive both benefits for the same

period of time.

HINTS: Are your statements legible? Would your statements make sense to someone who has never done your job? Do your

statements answer the questions? Are your statements complete and accurate? A NARRATIVE REPORT FROM YOUR PHYSICIAN

IS REQUIRED. Reports on medical forms, such as Form CA-20, are rarely adequate in occupational disease cases.

NOTICE TO COMPENSATION SPECIALISTS AND SUPERVISORS

OWCP needs your help to improve the timeliness of adjudication of occupational disease cases. We have developed checklists

to help you and the employee submit a claim in an organized and complete manner. The checklists will help the claims examiner

identify what information has been submitted and what is still outstanding.

Whenever an employee wants to file a claim for occupational disease or illness, please give him or her:

1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and

2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to

mark and return with the completed package. The second checklist is for the employee to take to the physician.

In addition to describing the evidence required from the employee, the checklists describe the information to be submitted by the

employing agency. When Form CA-2 and the employee's statements are returned, you are required by instructions on the CA-2 to

forward them to OWCP within ten working days. Statements and documents required from the agency should be submitted with

the CA-2 whenever possible. Please use the checklist to note what information from the employing agency is enclosed,

unavailable or pending. If pending, please give the anticipated mailing date. Agency comments, statements and documentation

are essential for the examiner to get a well rounded picture of the employment conditions.

We appreciate your cooperation in this effort.