HBK EL 505 INJURY COMPENSATION, DECEMBER 1995 F

1 HBK EL-505, INJURY compensation , DECEMBER 1995 FORMS371 OWCP Form CA-2 InstructionsNotice of Occupational Disease and Claim for CompensationSummaryPurposeOfficial notice to the employee s supervisor and to the OWCP of a conditionbelieved by the employee to have been caused, aggravated, or accelerated byfactors of his or her work Procedures and Preparation Responsibilitiesa. The employee, or the employee s representative, desiring to report an illnessor disease is provided a CA-2 by the employee s supervisor. At this time, thesupervisor will review the employee s instructions for completing Form CA-2that are attached to the CA-2. He or she will ensure that the employee or therepresentative is aware of the data requirements and the need for a narrativestatement from the : The employee will also be provided two or more copies of theappropriate evidence checklist, OWCP Form CA-35 one for eachphysician and one for the After completing the form and preparing the statement, the employee willsubmit the form and statement to the supervisor or the designated agencyofficial.

2 At this time, the employee may submit the required medical data orhave made arrangements for such to be The supervisor, after ensuring that the form is complete, gives the employeeor the representative the receipt attached to the The supervisor completes the superior s portion of the form, leaving blankthose Items for which he or she does not have The supervisor prepares a statement commenting on the accuracy of detailsin the statement submitted by or on behalf of the supervisor prepares Form 1769, Accident The supervisor submits the CA-2, the employee s and the supervisor sstatement, medical reports if received, and a copy of the Form 1769 to the ICcontrol office or control The employee or the representative should submit the claim within 30 daysafter realizing that the disease or illness was caused, aggravated, oraccelerated by the The control office must forward the CA-2 and supporting documentation tothe OWCP within 10 working days after receipt from the employee.

3 If theHBK EL-505, INJURY compensation , DECEMBER 1995 FORMS372employee did not submit the required statement and medical data, he or sheshould be apprised of the fact that failure to comply with the instructionscould jeopardize the acceptance of the claim. If the CA-2 is submitted withoutthe supporting data, submit the form to the OWCP with a memo stating thatthe employee was apprised of the need to submit the additional data, but hasfailed to do When notified by the OWCP that the claim has been either accepted orrejected, the control office must notify the safety office to initiate appropriateaction relative to the Form and Distributiona. 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 sealedenvelope if no OMF is available.(2) Send a copy to the IC claim file notated: Original in OPF.

4 (3) Send a copy to the safety office, after deleting any sensitive If the claim is reported to the OWCP:(1) Forward the original CA-2 to the district OWCP by either the IC controloffice or by the office or installation designated to correspond with theOWCP.(2) Place a copy in the IC claim file.(3) Send a copy to the safety office, after deleting any sensitive CompletionEmployee s Portion of the Form, Items 1 1 through 18 will be completed either by the claimant (employee) or by hisor her : The shaded blocks a, b, and c will be completed by the IC following instructions should be followed when completing the employee sportion of the form. Items not listed are : a. Insert appropriate designation, , PS-5/9, EAS-16/18, EAS-20, PCES, EL-505, INJURY compensation , DECEMBER 1995 FORMS373b. Considering the location identified in Items 10 and 13, refer to item 29 forthe date the claimant was last exposed to the conditions alleged to havecaused the disease or illness, , date employee last worked, etc.

5 If theclaimant is still working in the area of exposure, give current If other, in item is checked, have employee submit related information, ,identify dependent parents, brothers, sisters, grandparents, or grandchildrenwho are dependent on the appropriate box(es). If other is checked, have employee submitrelated information on an attachment; , identify children aged 18 through22 who are either full-time students or who are unable to care for themselves,identify dependent parents, brothers, sister, grandparents or note that married children cannot be claimed as dependents evenwhen residing with the parent. Also, if child support is paid for children livingelsewhere due to a divorce or separation, a copy of the court order is to The title requested is the formal title of the employee s position within thePostal Service.

6 This Item will be used by the HRS to identify the code to beinserted into shaded block Exact location where the claimant alleges he or she was exposed toconditions causing the illness or disease. Be sure that the location identifiedcan be located by his or her immediate The date the employee first became aware of the illness or disease; this datemay 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 Be sure that the specificity required on the instruction page of the form isprovided, , right, left, inside thigh, Do not leave blank. Enter NA if employee s statement has been received Do not leave blank. Enter NA if medical documentation has been receivedor a. The employee or the representative should be aware of the certificationstatement in this Item and the penalty notice which The date should be the date the form is submitted to either the supervisoror a management Supervisor s Portion of the Form, Items 19 19 through 34 will be completed either by the immediate supervisor or bythe control EL-505, INJURY compensation , DECEMBER 1995 FORMS374 The following instructions should be followed when completing the supervisor sportion of the form; Items not listed are : Explanation19.

7 Per instructions on the form and USPS policy, this is the identification andaddress of the control office authorized to communicate with the districtOWCP, this is the office authorized to receive correspondence from theOWCP. This is not always the installation in which the injured employee isemployed. See Item The OWCP Agency Code will be entered by INJURY compensation The OSHA Site Code is not Enter the name and full address of the installation in which the injuredemployee is employed. This could be an associate office, a branch, a station,a repair facility, a VMF, a. If claimant has fixed duty hours, enter start and end If claimant has variable or flexible hours, enter Variable, DOI (Date ofInjury) hours listed, and then enter work schedule for a. If claimant has a fixed schedule, check the scheduled If claimant has either a rotating (carrier) or flexible schedule, or a variableworkday schedule, enter either Variable or Rotating and enter week ofinjury; check the days worked during the week of the This item is completed with information related to the first physician whoprovided medical care for the disease or illness (see 5 8101 (2) fordefinition of a physician).

8 Note: If initial care was given by a nurse or other health professional (not aphysician), indicate this on a separate attachment. The attachment shouldinclude the name, position, date of treatment, diagnosis, and address of thehealth professional. Physician s assistants reports must be countersigned bya physician to be This date is the date of the first visit to the physician listed in Item Consider only medical reports form countersigned by a. This Item refers to the first tour of duty or date on which the injuredemployee either did not report to work, or stopped work, due to disabilitycaused by illness or disease identified in Item The time entry is either the start time of the first tour of duty missed, orthe actual time the employee departed the work area or installation dueto If claimant is not disabled, enter Did Not Stop Work.

9 HBK EL-505, INJURY compensation , DECEMBER 1995 FORMS37528. A date is entered only if the employee enters into a leave without pay (LWOP)status caused by absence due to the illness or Identify the date the employee was last exposed to the conditions alleged tohave caused or aggravated the disease or illness. This could be the last dayon the job before a transfer to another location, the last day on the job beforeperiod of disability, If the employee did not stop work, , no disability, enter Did Not StopWork. Remember that this Item must agree with Item If the employee has been assigned to either light or limited duty because ofmedically prescribed limitations, attach a copy of the written job descriptionfor such A third party is an individual or organization (other than the injured employeeor the federal government) who is liable for the illness or Supervisors should be apprised of the penalty warning contained in this Item,and they should enter their commercial telephone Receipt of Notice of INJURY is required to be presented to the employee or therepresentative at the time the form is submitted to management.

10 Such receipt isthe evidence an employee needs to prove not only that a claim was submitted inthe event that the original documents are lost, but also to show the timeliness ofthe claim s submission. When the form is completed, it must be completed in itsentirely. At this time, the employee or the representative should be advised thatthe receipt should be retained in a safe place to ensure that it is available in Disease ChecklistsCA-35A, Evidence Required in Support of a Claim for Occupational DiseaseCA-35B, Evidence Required in Support of a Claim for Work-Related HearingLossCA-35C, Evidence Required in Support of a Claim for Asbestos-Related IllnessCA-35D, Evidence Required in Support of a Claim for Work-RelatedCoronary/Vascular ConditionCA-35E, Evidence Required in Support of a Claim for Work-Related SkinDiseaseCA-35F, Evidence Required in Support of a Claim for Work-Related PulmonaryIllness (not asbestosis)