Federal Employees’ Compensation Act (FECA) Forms:

  The FECA provides compensation benefits to civilian employees of the United States for disability due to personal injury or disease sustained while in the performance of duty. The FECA also provides for payment of benefits to dependents if a work-related injury or disease causes an employee’s death.

Basic Forms:

CA-1 Notice of Traumatic Injury (Explanation) (Interactive PDF)

CA-2* Notice of Occupational Disease and Claim for Compensation (Explanation) (PDF)

CA-2a Notice of Recurrence of Disability  (Explanation) (interactive PDF)

CA-5 Claim for Compensation by Widow, Widower, and/or Children (PDF)

CA-6, Official Supervisor's Report of Employee's Death (PDF)

CA-7 Claim for Compensation on Account of Traumatic Injury or Occupational Disease                                                     (Explanation) (interactive PDF)

CA-16 Authorization for Examination and/or Treatment (Explanation)

CA-17, Duty Status Report PDF

CA-20 Attending Physician’s Report (.PDF)

CA-915 Claimant Medical Reimbursement Form (interactive PDF)

*Additional Forms for the CA-2

The Federal Employees’ Compensation Program has developed eight checklists to assist employees and agency personnel in gathering and submitting material required for adjudication of occupational disease claims. The following forms are in addition to the CA-2.

CA-35a Occupational Disease in General

CA-35b Hearing Loss

CA-35c Asbestos-Related Illness

CA-35d Coronary/Vascular Condition

CA-35e Skin Disease

CA-35f Pulmonary Illness (NOT Asbestosis)

CA-35g Psychiatric Illness

CA-35h Carpal Tunnel Syndrome

HCFA-1500, Health Insurance Claim Form (PDF)

-Traumatic Injury – Notice of Injury – Form CA-1:

A traumatic injury is defined as a wound or other condition of the body caused by external force, including stress or strain. When an employee sustains a traumatic injury in the performance of duty, he or she should file a written report on Form CA-1. The form should be given to the supervisor as soon as possible, but not later than 30 days from the date of injury. If the employee is incapacitated, this action may be taken by someone acting on his/her behalf, including a family member, union official or representative. The form must contain the original signature of the person giving notice.

-Medical Treatment – Form CA-16:

If an employee requires medical treatment for the injury, the Safety Office should complete the front of the Form CA-16 within four hours of the request whenever possible. Where there is no time to complete a Form CA-16, the Safety Office or supervisor may authorize medical treatment by telephone and send the completed form to the medical facility within 48 hours. Retroactive issuance of Form CA-16 is not permitted under other circumstances. Agency personnel are encouraged to use discretion in issuing authorizations for medical care under such circumstances, but employee should not be penalized for short delays in reporting injuries.

The employee is entitled to select the physician who is to provide treatment. The provider must meet the definition of "physician" under the FECA and must not have been excluded from payment under the program. Chiropractors – Under the FECA, the services of chiropractors may be reimbursed only for treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist. The term "subluxation" is defined as an incomplete dislocation, off-centering, misalignment, fixation or abnormal spacing of the vertebrae anatomically which must be demonstrable on any X-ray film to individuals trained in the reading of X-rays. Chiropractors may interpret their own X-rays, and if a subluxation is diagnosed, OWCP will accept the chiropractor’s assessment of any disability caused by it.

-Occupational Disease – Form CA 2:

An occupational disease is defined as a condition produced in the work environment over a period longer than one workday or shift. It may result from systemic infection, repeated stress or strain, exposure to toxins, poisons, or fumes, or other continuing conditions of the work environment. A CA-16 is never issued for an occupational disease claims. The employee has the right to elect sick or annual leave or leave without pay, pending adjudication of the claim. The supervisor should submit completed Form CA-2 to the Safety Office within 10 working days of receipt from the employee. It should not be held for receipt of supporting documentation.

-Recurrences – Form CA-2a:

A recurrence of disability is defined as a spontaneous return or increase of disability due to a previous injury or occupational disease without intervening cause, or a return or increase of disability due to a consequential injury. A recurrence of disability differs from a new injury in that with a recurrence, no event other than the previous injury accounts for the disability.

-Wage Loss/Permanent Impairment – Form CA-7:

Form CA-7 is used to file a claim for compensation because of pay loss. The claim should be filed within 10 days after pay stops or when the employee returns to work, whichever occurs first.

1) Leave Repurchase – The employee may use sick or annual leave pending adjudication of the claim. If this is done, the employee may initiate repurchase of this leave, subject to agency concurrence, using CA-7 (along with Forms CA-7a and CA-7b). The supervisor should certify the amount and kind of leave used for each day claimed, and the employee should arrange to submit medical evidence supporting the period of repurchase requested.

2) Lost Wages for Medical Treatment – An employee who has returned to work but still needs medical treatment during work hours may claim compensation for lost wages while undergoing or traveling to and from the treatment. For a routine medical appointment, a maximum of four hours of compensation is usually allowed. Such a claim may be made on Form CA-7, and it should be accompanied by a statement from the supervisor showing the exact period of time and the total amount of wages lost due to the treatment, as well as the rate of pay.

Form CA-7 is also used to claim continuing compensation and to initiate a claim for schedule award for permanent impairment resulting from occupational disease.