Summary HBK EL-505, INJURY COMPENSATION, DECEMBER 1995 FORMS. OWCP Form CA-2 Instructions Notice of Occupational Disease and Claim for Compensation

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Blake Benson
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1 OWCP Form CA-2 Instructions Notice of Occupational Disease and Claim for Compensation Summary Purpose Official notice to the employee s supervisor and to the OWCP of a condition believed by the employee to have been caused, aggravated, or accelerated by factors of his or her work environment. General Procedures and Preparation Responsibilities a. The employee, or the employee s representative, desiring to report an illness or disease is provided a CA-2 by the employee s supervisor. At this time, the supervisor will review the employee s instructions for completing Form CA-2 that are attached to the CA-2. He or she will ensure that the employee or the representative is aware of the data requirements and the need for a narrative statement from the employee. Note: The employee will also be provided two or more copies of the appropriate evidence checklist, OWCP Form CA-35 one for each physician and one for the employee. b. After completing the form and preparing the statement, the employee will submit the form and statement to the supervisor or the designated agency official. At this time, the employee may submit the required medical data or have made arrangements for such to be submitted. c. The supervisor, after ensuring that the form is complete, gives the employee or the representative the receipt attached to the CA-2. d. The supervisor completes the superior s portion of the form, leaving blank those Items for which he or she does not have information. e. The supervisor prepares a statement commenting on the accuracy of details in the statement submitted by or on behalf of the employee. f. The supervisor prepares Form 1769, Accident Report. g. The supervisor submits the CA-2, the employee s and the supervisor s statement, medical reports if received, and a copy of the Form 1769 to the IC control office or control point. Timeliness a. The employee or the representative should submit the claim within 30 days after realizing that the disease or illness was caused, aggravated, or accelerated by the employment. b. The control office must forward the CA-2 and supporting documentation to the OWCP within 10 working days after receipt from the employee. If the 371

2 employee did not submit the required statement and medical data, he or she should be apprised of the fact that failure to comply with the instructions could jeopardize the acceptance of the claim. If the CA-2 is submitted without the supporting data, submit the form to the OWCP with a memo stating that the employee was apprised of the need to submit the additional data, but has failed to do so. c. When notified by the OWCP that the claim has been either accepted or rejected, the control office must notify the safety office to initiate appropriate action relative to the Form Filing and Distribution a. If the claim is not reported to the OWCP do the following: (1) File the original Form CA-2 in the employee s OMF; use a sealed envelope if no OMF is available. (2) Send a copy to the IC claim file notated: Original in OPF. (3) Send a copy to the safety office, after deleting any sensitive medical information. b. If the claim is reported to the OWCP: (1) Forward the original CA-2 to the district OWCP by either the IC control office or by the office or installation designated to correspond with the OWCP. (2) Place a copy in the IC claim file. (3) Send a copy to the safety office, after deleting any sensitive medical information. Instructions Forms Completion Employee s Portion of the Form, Items Items 1 through 18 will be completed either by the claimant (employee) or by his or her representative. Exceptions: The shaded blocks a, b, and c will be completed by the IC control office. The following instructions should be followed when completing the employee s portion of the form. Items not listed are self-explanatory. Item: Explanation a. Insert appropriate designation, i.e., PS-5/9, EAS-16/18, EAS-20, PCES, etc. 372

3 b. Considering the location identified in Items 10 and 13, refer to item 29 for the date the claimant was last exposed to the conditions alleged to have caused the disease or illness, i.e., date employee last worked, etc. If the claimant is still working in the area of exposure, give current grade information If other, in item is checked, have employee submit related information, e.g., identify dependent parents, brothers, sisters, grandparents, or grandchildren who are dependent on the employee. Check appropriate box(es). If other is checked, have employee submit related information on an attachment; e.g., identify children aged 18 through 22 who are either full-time students or who are unable to care for themselves, identify dependent parents, brothers, sister, grandparents or grandchildren. Please note that married children cannot be claimed as dependents even when residing with the parent. Also, if child support is paid for children living elsewhere due to a divorce or separation, a copy of the court order is to be attached. 9. The title requested is the formal title of the employee s position within the Postal Service. This Item will be used by the HRS to identify the code to be inserted into shaded block a. 10. Exact location where the claimant alleges he or she was exposed to conditions causing the illness or disease. Be sure that the location identified can be located by his or her immediate supervisor. 11. The date the employee first became aware of the illness or disease; this date may or may not agree with Item The employee should identify the specific conditions, substances, activities, etc., which he or she believes are responsible for the illness or disease. 14. Be sure that the specificity required on the instruction page of the form is provided, e.g., right, left, inside thigh, etc Do not leave blank. Enter NA if employee s statement has been received or submitted. 17. Do not leave blank. Enter NA if medical documentation has been received or submitted. 18. a. The employee or the representative should be aware of the certification statement in this Item and the penalty notice which follows. b. The date should be the date the form is submitted to either the supervisor or a management representative. Official Supervisor s Portion of the Form, Items Items 19 through 34 will be completed either by the immediate supervisor or by the control office. 373

4 The following instructions should be followed when completing the supervisor s portion of the form; Items not listed are self-explanatory. Note: Explanation 19. Per instructions on the form and USPS policy, this is the identification and address of the control office authorized to communicate with the district OWCP, this is the office authorized to receive correspondence from the OWCP. This is not always the installation in which the injured employee is employed. See Item 20. a. The OWCP Agency Code will be entered by injury compensation control personnel. b. The OSHA Site Code is not required. 20. Enter the name and full address of the installation in which the injured employee is employed. This could be an associate office, a branch, a station, a repair facility, a VMF, etc. 21. a. If claimant has fixed duty hours, enter start and end times. b. If claimant has variable or flexible hours, enter Variable, DOI (Date of Injury) hours listed, and then enter work schedule for DOI. 22. a. If claimant has a fixed schedule, check the scheduled days. b. If claimant has either a rotating (carrier) or flexible schedule, or a variable workday schedule, enter either Variable or Rotating and enter week of injury; check the days worked during the week of the injury. 23. This item is completed with information related to the first physician who provided medical care for the disease or illness (see 5 U.S.C 8101 (2) for definition of a physician). Note: If initial care was given by a nurse or other health professional (not a physician), indicate this on a separate attachment. The attachment should include the name, position, date of treatment, diagnosis, and address of the health professional. Physician s assistants reports must be countersigned by a physician to be acceptable. 24. This date is the date of the first visit to the physician listed in Item Consider only medical reports form countersigned by physicians a. This Item refers to the first tour of duty or date on which the injured employee either did not report to work, or stopped work, due to disability caused by illness or disease identified in Item 14. b. The time entry is either the start time of the first tour of duty missed, or the actual time the employee departed the work area or installation due to disability. c. If claimant is not disabled, enter Did Not Stop Work. 374

5 28. A date is entered only if the employee enters into a leave without pay (LWOP) status caused by absence due to the illness or disease. 29. Identify the date the employee was last exposed to the conditions alleged to have caused or aggravated the disease or illness. This could be the last day on the job before a transfer to another location, the last day on the job before period of disability, etc. 30. If the employee did not stop work, i.e., no disability, enter Did Not Stop Work. Remember that this Item must agree with Item If the employee has been assigned to either light or limited duty because of medically prescribed limitations, attach a copy of the written job description for such duty. 32. A third party is an individual or organization (other than the injured employee or the federal government) who is liable for the illness or disease Supervisors should be apprised of the penalty warning contained in this Item, and they should enter their commercial telephone number. The Receipt of Notice of Injury is required to be presented to the employee or the representative at the time the form is submitted to management. Such receipt is the evidence an employee needs to prove not only that a claim was submitted in the event that the original documents are lost, but also to show the timeliness of the claim s submission. When the form is completed, it must be completed in its entirely. At this time, the employee or the representative should be advised that the receipt should be retained in a safe place to ensure that it is available in the future. Occupational Disease Checklists CA-35A, Evidence Required in Support of a Claim for Occupational Disease CA-35B, Evidence Required in Support of a Claim for Work-Related Hearing Loss CA-35C, Evidence Required in Support of a Claim for Asbestos-Related Illness CA-35D, Evidence Required in Support of a Claim for Work-Related Coronary/Vascular Condition CA-35E, Evidence Required in Support of a Claim for Work-Related Skin Disease CA-35F, Evidence Required in Support of a Claim for Work-Related Pulmonary Illness (not asbestosis) CA-35G, Evidence Required in Support of a Claim for Work-Related Psychiatric Illness CA-35H, Evidence Required in Support of a Claim for Work-Related Carpal Tunnel Syndrome 375

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Santa Ana Police Department

Santa Ana Police Department Departmental Order #250 - Procedures Relating to Industrial and Non- Industrial Injuries and Illnesses Purpose.......................................................................