Form CA-2 at a glance
What it is: Form CA-2 is the Notice of Occupational Disease and Claim for Compensation of the U.S. Department of Labor, Office of Workers' Compensation Programs.
Where and when to file: Complete items 1 through 18 and submit the form to the employee's supervisor along with the statement and medical reports.
Employee: Please complete all boxes 1 - 18. Do not complete shaded areas. Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.
A filled-in Form CA-2 example: an employee files a notice of occupational disease
How to fill out Form CA-2, box by box
Employee Data
Enter the Name of Employee (Last, First, Middle) in box 1 and the Social Security Number in box 2.
Injured workers should provide an email address in box 1a when completing this form.
Enter the Date of birth (Mo. Day Yr.) in box 3, the Sex in box 4, the Home telephone in box 5, and the Grade as of date of last exposure, with Level and Step, in box 6.
Employee's home mailing address and Dependents
Enter the Employee's home mailing address (include street address, city, state, and ZIP code) in box 7.
Box 8, Dependents, lists Wife, Husband, Children under 18 years, and Other.
Claim Information
Enter the Employee's occupation in box 9.
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.
Enter the Location where you worked when disease or illness occurred (include street address, city, state, and ZIP code) in box 10.
Enter the Date you first became aware of disease or illness in box 11.
Enter the Date you first realized the disease or illness was caused or aggravated by your employment in box 12.
Explain the relationship to your employment, and why you came to this realization in box 13.
Enter the Nature of disease or illness in box 14: give a complete description of the disease or illness, and specify the left or right side if applicable (e.g., rash on left leg; carpal tunnel syndrome, right wrist).
Reason for the delay
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 in box 15.
If the statement requested in item I of the attached instructions is not submitted with this form, explain reason for delay in box 16.
If the medical reports requested in item 2 of attached instructions are not submitted with this form, explain reason for delay in box 17.
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.
More rules for Form CA-2
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.
1) Employee's statement: in a separate narrative statement attached to the form, the employee must submit the following information: a detailed history of the disease or illness from the date it started. The statement gives complete details of the conditions of employment which are believed to be responsible for the disease or illness. The statement describes specific exposures to substances or stressful 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. 2) Medical report: dates of examination or treatment, history given to the physician by the employee, detailed description of the physician's findings, results of x-rays, laboratory tests, etc., diagnosis, and clinical course of treatment. The report gives the 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.
A medical report also gives the identification of the part of the body affected, and medical reports that do not explain the basis for the physician's opinion are given very little weight in adjudicating the claim.
3) Wage loss: If you have lost wages or used leave for this illness, Form CA-7 should also be submitted.
You 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).
Have your supervisor complete the receipt attached to this form and return it to you for your records.
Common questions about Form CA-2
What is a CA-2 form used for?
The FECA, which is administered by the Office of Workers' Compensation Programs (OWCP), provides general benefits for employment-related occupational disease or illness.
Who signs it?
Date, Signature of employee or person acting on his/her behalf.
Where do I file it?
Complete items 1 through 18 and submit the form to the employee's supervisor along with the statement and medical reports.
Is there a penalty?
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.
What am I certifying when I sign?
By signing you certify, under penalty of law, that the disease or illness was the result of your employment with the United States Government, and that it was not caused by your willful misconduct, by "intent to injure myself or another person", nor by your intoxication. By signing you also claim medical treatment, if needed, and other benefits provided by the Federal Employees' Compensation Act.
Sources
[1] Form CA-2 (Rev. October 2018), Notice of Occupational Disease and Claim for Compensation, U.S. Department of Labor (the Official source link on this page).