(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.
Information in Program Records