FORMS AND NOTICES

CA-1 Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation

The employee, or someone acting on his or her behalf, should submit the CA-1 to the supervisor as soon as possible following injury, but no later than 30 days for COP entitlement. Statutory requirements will be met for FECA benefits if the CA-1 is filed within 3 years from the injury. The supervisor should submit this form to the Injury Compensation Control Office (ICCO) within 24 hours from receipt from the employee. The ICCO must submit this form to OWCP within 10 working days from the date received by the supervisor from the employee.

CA-2 Notice of Occupational Disease and Claim for Compensation

This form has the same time limitations for submission as the CA-1 listed above.

CA-2a Federal Employee's Notice of Recurrence of Disability and Claim of Pay/Compensation

This form has the same time limitations for submission as above.

CA-3, Report of Termination of Disability and/or Payment

The CA-3 notifies OWCP that the employee has returned to work and/or that continuation of pay has terminated. Immediately upon the employee's return to work, the ICCO submits the CA-3 to OWCP. The CA-3 is the preferred form recognized by both agencies even though the employee's return to work may be reported on the CA-7 or the CA-17.

CA-7, Claim for Compensation on Account of Traumatic Injury or Occupational Disease

The CA-7 is used to claim compensation. When the disability is expected to extend beyond the COP period in traumatic injury cases, the ICCO provides the employee with a CA-7 10 days before the end of the COP period. The employee is instructed to complete his or her portion, have the attending physician complete the CA-20. The ICCO submits the completed CA-7 to OWCP not less than 5 working days before termination of COP. In occupational disease claims, a CA-7 should be submitted along with the CA-2 if the disability is being claimed at that time. In other instances, the CA-7 is completed and submitted to OWCP not more than 5 days after the period claimed by the employee.

CA-8, Claim for Continuing Compensation on Account of Disability

The CA-8 claims compensation when disability continues beyond the time covered by the claim on the CA-7. CA-8s are filed on a recurring basis (usually every 2 weeks) until advised otherwise by OWCP. If disability is expected to continue, the ICCO provides the employee with the CA-8 at least 10 days before the end of the time indicated on either the CA-7 or the previous CA-8. The employee completes his or her portion, and has the attending physician complete the CA-20a. The ICCO submit the completed CA-8 to OWCP at least 5 days before the end of the period claimed on the CA-7 or the previous CA-8.

CA-10, What a Federal Employee Should Do When Injured at Work

The CA-10 provides employees with information regarding their rights, responsibilities, and benefits under FECA. The CA-10 is to be posted on employee bulletin boards.

CA-11, When Injured at Work

This pamphlet provides facts about medical benefits, disability, compensation for death, and other entitlements for civilian employees of the federal government. The CA-11 should be handed out during employee orientation.

CA-13, Work Injury Benefits for Federal Employees

The CA-13 is a card for federal employees to carry in their wallets as a reference. It provides instructions for employees and their families in the event of an employment-related injury or death. The CA-13 should be handed out during employee orientation.

CA-16, Authorization for Examination and/or Treatment

The CA-16 authorizes an injured employee to obtain examination and/or treatment for up to 60 days and provides OWCP with an initial medical report. The CA-16 forms are issued by the ICCO or trained control point personnel only. The CA-16 must be promptly issued within 4 hours in traumatic injuries requiring medical attention, except first-aid injuries where the employee has elected treatment by a contract medical provider. CA-16s are rarely used for occupational illness or disease claims and only with prior OWCP approval. If the employee chooses to select a contract medical provider beyond first-aid treatment, the CA-16 should be issued in accordance with FECA for the employee's selection of the contract medical provider as the employee's treating physician.

CA-17, Duty Status Report

The CA-17 provides management and OWCP with an interim medical report containing information as to the employee's ability to return to any type of work. Initially issued by the supervisor at the time of injury, subsequent issuances are performed by either the ICCO or control point personnel. The employee is responsible for having the attending physician complete the CA-17 at each visit when there is a change in medical condition and for its prompt return to the ICCO or control point. The ICCO submits the completed form to OWCP within 10 days from date of receipt.

CA-20, Attending Physician's Report

The CA-20 provides medical support for claims and is attached to the CA-7 which provides the ICCO and OWCP with medical information. The CA-20 is initially issued by the supervisor at the time of injury when the CA-16 is not used and when the injury is not a first-aid injury treated by a contract medical provider. Subsequent issuances are the same as for the CA-17. CA-20 must be submitted promptly to OWCP upon completion of most recent examination or treatment.

CA-20a, Attending Physician's Supplemental Report

The CA-20a provides OWCP with additional medical information in connection with a supplemental claim filed on an attached CA-8. A corresponding CA-20a is to be submitted with each CA-8 filed. The CA-20a must be submitted promptly to OWCP upon completion of most recent examination or treatment.

Evidence Required in Support of a Claim for:

35A, Occupational Disease
35B, Work-Related Hearing Loss
35C, Asbestos-Related Illness
35D, Work-Related Coronary/Vascular Condition
35E, Work-Related Skin Disease
35F, Work-Related Pulmonary Illness (not asbestosis)
35G, Work-Related Psychiatric Illness
35H, Work-Related Carpal Tunnel Syndrome

The 35A-through-H series of forms provides the employee and management with a checklist of information required from both parties in order for OWCP to adjudicate the respective occupational illness or disease claim. These forms should be submitted with the CA-2.

HCFA-1500, Health Insurance Claim Form

This form provides OWCP with a standard billing form to facilitate payment of medical bills. The HCFA-1500 is issued along with the CA-16, the CA-20, and the CA-17 when the employee is scheduled for medical examination and/or treatment.

Form 2556, Third Party Statement of Recovery

Form 2556 provides OWCP and the USPS with a breakdown of disbursements made from moneys recovered from a third party pursuit. This form is used when the employee is represented by an attorney or has assigned the action to the USPS. Upon the employee's recovery, the form must be completed promptly and forwarded to OWCP with a check for the government's lien by the ICCO.

Form 2573, Request - OWCP Claim Status

Form 2573 provides a standard format for requesting general claim status information from OWCP.

Publication 71, Notice for Employees Requesting Leave for Conditions Covered by the Family and Medical Leave Act

When an employee is absent from work because of an FMLA-covered injury or illness, a copy of Publication 71 is given to him or her along with the modified letter called Employee Rights, Responsibilities, and Choice of Physician.

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