Ca 2 Form – Fill Out and Use This PDF

The CA-2 form, titled Notice of Occupational Disease and Claim for Compensation, is a document issued by the U.S. Department of Labor's Office of Workers' Compensation Programs. It is designed for federal employees to report a work-related illness or disease and to claim for compensation benefits. Individuals are required to fill out all specified sections, whereas shaded areas are reserved for completion by employing agency representatives. Click the button below to fill out your CA-2 form accurately and ensure your claim is processed efficiently.

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Ca 2 Form PDF Details

Navigating the intricacies of workplace injuries and diseases under the Federal Employees' Compensation Act (FECA) can be daunting for both employees and employers alike. The CA-2 Form, officially known as the "Notice of Occupational Disease and Claim for Compensation," serves as a critical tool in this process, managed by the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP). This form is meticulously designed to compile comprehensive information regarding the employee's condition, its correlation to their employment, and the claim for compensation and benefits owed under the FECA. It requires detailed input from the employee, including personal information, a descriptive account of the occupational disease or illness, its direct link to the work environment, and an authorization for medical disclosure. On the flip side, employers or supervisors have the responsibility to corroborate these details, supplement the form with additional evidence, and ensure its timely submission to OWCP. This dual participation underscores the form's pivotal role in substantiating claims for medical care, wage loss compensation, and other benefits aimed at assisting federal employees in their recovery and rehabilitation. However, the stakes of misrepresentation either by omission or commission are high, as it may lead to serious legal implications, including felony criminal prosecution. Hence, understanding and accurately completing the CA-2 Form is paramount in navigating the FECA claims process efficiently and ethically.

Question	Answer
Form Name	Ca 2 Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	ca 1 or ca 2, form ca2, dol gov ca 2, ca2

Form Preview Example

Notice of Occupational Disease	RESET PRINT	U.S. Department of Labor
and Claim for Compensation		Office of Workers' Compensation Programs
		Office of Workers' Compensation Programs

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.

Employee Data

1. Name of Employee (Last, First, Middle)							1a. Email Address

2. Social Security Number

3. Date of birth	Mo. Day Yr.

4. Sex

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)

City		State			ZIP Code

8. Dependents

Wife, Husband

Children under 18 years

Other

Claim Information

9.Employee's occupation

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

City	State	ZIP Code

a. Occupation code

11.Date you first became aware of disease

or illness

Mo. Day Yr.

12. Date you first realized

the disease or illness Mo. Day Yr. was caused or aggravated

by your employment

13. Explain the relationship to your employment, and why you came to this realization

14. Nature of disease or illness

OWCP Use - NOI Code

	b. Type code		c. Source code

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.

Employee Signature

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.

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.

	Form CA-2
For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC 20402	Rev. October 2018

Official Supervisor's Report of Occupational Disease: Please complete information requested below

Supervisor's Report

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

a.m.

22. Regular

work

Thurs.

hours From:

p.m.

To:

p.m.

schedule

Sun.

Mon.

Tues.

Wed.

Fri.

Sat.

23. Name and address of physician first providing medical care (include city, state, ZIP code)

24. First date

Mo.

Day

medical

care received

25. Do medical reports

Yes

show employee is

City

State

ZIP Code

disabled for work?

26. Date employee

Mo.

Day

27. Date and

Mo.

Day

a.m.

first reported

hour employee

Time

p.m.

condition to

stopped work

supervisor

28. Date and

Mo.

Day

a.m.

29. Date employee was last

Mo. Day

hour employee's

Time

p.m.

exposed to conditions

pay stopped

alleged to have caused

disease or illness

30.Date returned to work

Mo. Day

Time

a.m.

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 34.

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

City	State			ZIP Code

Signature of Supervisor

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
Signature of Supervisor			Date

Supervisor's Title			Office phone

Form CA-2

Rev. October 2018

Page 2

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

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:

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

hospitals, or private hospitals or physicians of the employee's choice.

(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.

(4)Vocational rehabilitation and related services where necessary.

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.

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.

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.)

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.

Privacy Act

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.

Receipt of Notice of Occupational Disease or Illness

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)

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

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

Form CA-2

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.

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

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.

	1) Employee's statement	2) Medical report
	In a separate narrative statement attached to the form, the	a) Dates of examination or treatment.
		a) Dates of examination or treatment.
	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.
	started.
	b) Complete details of the conditions of employment which are	c) Detailed description of the physician's findings.

	believed to be responsible for the disease or illness.	d) Results of x-rays, laboratory tests, etc.
		d) Results of x-rays, laboratory tests, etc.
	c) A description of specific exposures to substances or stress-	e) Diagnosis.
	ful conditions causing the disease or illness, including	e) Diagnosis.
	ful conditions causing the disease or illness, including
	locations where exposure or stress occurred, as well as	f) Clinical course of treatment.
	the number of hours per day and days per week of such	f) Clinical course of treatment.
	the number of hours per day and days per week of such
	exposure or stress.	g) Physician's opinion as to whether the disease or illness
		g) Physician's opinion as to whether the disease or illness
	d) Identification of the part of the body affected. (If disability	was caused or aggravated by the employment, along with
		an explanation of the basis for this opinion. (Medical
	is due to a heart condition, give complete details of all	an explanation of the basis for this opinion. (Medical
	is due to a heart condition, give complete details of all	reports that do not explain the basis for the physician's
	activities for one week prior to the attack with particular	reports that do not explain the basis for the physician's
	activities for one week prior to the attack with particular	opinion are given very little weight in adjudicating the
	attention to the final 24 hours of such period.)	opinion are given very little weight in adjudicating the
	attention to the final 24 hours of such period.)	claim.)
		claim.)
	e) A statement as to whether the employee ever suffered a	3) Wage loss
	similar condition. if so, provide full details of onset,	3) Wage loss
	similar condition. if so, provide full details of onset,
	history, and medical care received, along with names and	If you have lost wages or used leave for this illness, Form
	addresses of physicians rendering treatment.	CA-7 should also be submitted.

	Supervisor (Or appropriate official in the employing agency)

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
Identify fumes, chemicals, or other irritants or situations	by any similar disease or illness. Have the employee state the
that the employee was exposed to which allegedly caused	reason for each absence.

	the condition. State the nature, extent, and duration of the	d) Attach statements from each co-worker who has first-hand
	exposure, including hours per days and days per week,
		knowledge about the employee's condition and its cause. (The
	requested above.
		co-workers should state how such knowledge was obtained.)

	b) Attach copies of all medical reports (including x-ray reports	e) Review and comment on the accuracy of the employee's state-
	and laboratory data) on file for the employee.
		ment requested above.

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

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

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.

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.

24.First date medical care received

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

32.Employee's Retirement Coverage.

Indicate which retirement system the employee is covered

14. Nature of the disease or illness		under.
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	33. Was the injury caused by third party?
	tunnel syndrome, right wrist).	33. Was the injury caused by third party?
	tunnel syndrome, right wrist).	A third party is an individual or organization (other than the

		injured employee or the Federal government) who is liable for
19. Agency name and address of reporting office		the disease. For instance, manufacturer of a chemical to which
	The name and address of the office to which correspondence	an employee was exposed might be considered a third party if
	The name and address of the office to which correspondence
	from OWCP should be sent (if applicable, the address of the	improper instructions were given by the manufacturer for use of
	personnel or compensation office).	the chemical.

		Form CA-2
		Rev. Oct. 2018
		Page 4

INSTRUCTIONS FOR COMPLETING FORM CA-2 Continued

Employing Agency - Required Codes

Box a (Occupational Code), Box b. (Type Code), Box c	OWCP Agency Code
(Source Code), OSHA Site Code	This is a four digit (or four digit two letter) code used by OWCP
The Occupational Safety and Health Administration (OSHA)	to identify the employing agency. The proper code may be obtained
requires all employing agencies to complete these items when	from your personnel or compensation office, or by contacting OWCP.
reporting an injury. The proper codes may be found in OSHA
Booklet 2014, Record Keeping and Reporting Guidelines.

• U.S. GPO: 2001480-204/59062

Form CA-2

Rev. Oct. 2018

Page 5

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