Title 20
SECTION 10.7
10.7 What forms are needed to process claims under the FECA
§ 10.7 What forms are needed to process claims under the FECA?(a) Notice of injury, claims and certain specified reports shall be made on forms prescribed by OWCP. Employers shall not modify these forms or use substitute forms. Employers are expected to maintain an adequate supply of the basic forms needed for the proper recording and reporting of injuries.
| Form No. | Title |
|---|---|
| (1) CA-1 | Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. |
| (2) CA-2 | Notice of Occupational Disease and Claim for Compensation. |
| (3) CA-2a | Notice of Employee's Recurrence of Disability and Claim for Pay/Compensation. |
| (4) CA-3 | Report of Work Status. |
| (5) CA-5 | Claim for Compensation by Widow, Widower and/or Children. |
| (6) CA-5b | Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren. |
| (7) CA-6 | Official Superior's Report of Employee's Death. |
| (8) CA-7 | Claim for Compensation Due to Traumatic Injury or Occupational Disease. |
| (9) CA-7a | Time Analysis Form. |
| (10) CA-7b | Leave Buy Back (LBB) Worksheet/Certification and Election. |
| (11) CA-16 | Authorization of Examination and/or Treatment. |
| (12) CA-17 | Duty Status Report. |
| (13) CA-20 | Attending Physician's Report. |
| (14) CA-20a | Attending Physician's Supplemental Report. |
| (15) CA-40 | Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under Section 1105 of Public Law 110-181 (Section 8102a). |
| (16) CA-41 | Claim for Survivor Benefits Under the Federal Employees' Compensation Act Section 8102a Death Gratuity. |
| (17) CA-42 | Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity. |
| (18) CA-1108 | Statement of Recovery Letter with Long Form. |
| (19) CA-1122 | Statement of Recovery Letter with Short Form. |
(b) Copies of the forms listed in this paragraph are available for public inspection at the Office of Workers' Compensation Programs, U.S. Department of Labor, Washington, DC 20210. They may also be obtained from district offices, employers (i.e., safety and health offices, supervisors), and the Internet, at http://www.dol.gov.