| [613] | 1 | OOPSPC81 ;HIRMFO/YH-INSTRUCTIONS FOR COMPLETING FORM CA-2 (PART 2) ;5/4/98
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| 2 | ;;2.0;ASISTS;;Jun 03, 2002
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| 3 | EN1 ;
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| 4 | W !,"PU.5,16.4;LBa) Describe in detail the work performed by the employee. Identify@;"
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| 5 | W !,"PU11,16.4;LBc) Attach a record of the employee's absence from work caused@;"
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| 6 | W !,"PU1,16.1;LBfumes, chemicals, or other irritants or situations that the employ-@;"
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| 7 | W !,"PU11.5,16.1;LBby any similar disease or illness. Have the employee state the@;"
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| 8 | W !,"PU1,15.8;LBee was exposed to which allegedly caused the condition. State@;PU11.5,15.8;LBreason for each absence.@;"
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| 9 | W !,"PU1,15.5;LBthe nature, extent, and duration of the exposure, including hours@;"
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| 10 | W !,"PU11,15.4;LBd) Attach statements from each co-worker who has first-hand@;"
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| 11 | W !,"PU1,15.2;LBper days and days per week, requested above.@;PU11.5,15.1;LBknowledge about the employee's condition and its cause. (The@;"
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| 12 | W !,"PU.5,14.8;LBb) Attach copies of all medical reports (including x-ray reports and@;"
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| 13 | W !,"PU11.5,14.8;LBco-workers should state how such knowledge was obtained.)@;"
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| 14 | W !,"PU1,14.5;LBlaboratory data) on file for the employee.@;"
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| 15 | W !,"PU11,14.4;LBe) Review and comment on the accuracy of the employee's state-@;PU11.5,14.1;LBment requested above.@;"
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| 16 | W !,"PU.5,13.7;LBThe supervisor should also submit any other information or evidence pertinent @;"
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| 17 | W !,"LBto the merits of this claim.@;"
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| 18 | W !,"PU.5,13.5;PD22,13.5;SD1,277,2,1,4,9,5,0,6,2,7,23;PU.5,13.1;LBItem Explanations@;"
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| 19 | W !,"LB Some of the items on the form which may require further clarification are explained below.@;"
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| 20 | W !,"PU.5,13;PD22,13;PU.5,13;RA22,13.5;"
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| 21 | W !,"PU.5,12.5;LB14. Nature of the disease or illness@;"
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| 22 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 23 | W !,"PU1,12.1;LBGive a complete description of the disease or illness. Specify@;"
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| 24 | W !,"PU1,11.8;LBthe left or right side if applicable (e.g., rash on left leg; carpal@;"
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| 25 | W !,"PU1,11.5;LBtunnel syndrome, right wrist).@;"
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| 26 | W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
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| 27 | W !,"PU.5,10.8;LB19. Agency name and address of reporting office@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 28 | W !,"PU1,10.4;LBThe name and address of the office to which correspondence@;"
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| 29 | W !,"PU1,10.1;LBfrom OWCP should be sent (If applicable, the address of the@;"
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| 30 | W !,"PU1,9.8;LBpersonnel or compensation office).@;"
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| 31 | W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
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| 32 | W !,"PU.5,8.9;LB23. Name and address of physician first providing@;"
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| 33 | W !,"PU1,8.5;LBmedical care@;"
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| 34 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 35 | W !,"PU1,8.1;LBThe name and address of the physician who first provided@;"
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| 36 | W !,"PU1,7.8;LBmedical care for this injury. If initial care was given by a@;"
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| 37 | W !,"PU1,7.5;LBnurse or other health professional (not a physician) in the@;"
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| 38 | W !,"PU1,7.2;LBemploying agency's health unit or clinic, indicate this on a@;"
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| 39 | W !,"PU1,6.9;LBseparate sheet of paper.@;"
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| 40 | W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
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| 41 | W !,"PU11,12.5;LB24. First date medical care received@;"
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| 42 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 43 | W !,"PU11.5,12.2;LBThe date of the first visit to the physician listed in item 23.@;"
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| 44 | W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
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| 45 | W !,"PU11,10.8;LB32. Employee's Retirement Coverage.@;"
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| 46 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 47 | W !,"PU11.5,10.4;LBIndicate which retirement system the employee is covered@;"
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| 48 | W !,"PU11.5,10.1;LBunder.@;"
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| 49 | W !,"SD1,277,2,1,4,9,5,0,6,2,7,23;"
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| 50 | W !,"PU11,9.2;LB33. Was the injury caused by third party?@;"
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| 51 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 52 | W !,"PU11.5,8.9;LBA third party is an individual or organization (other than the@;"
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| 53 | W !,"PU11.5,8.6;LBinjured employee or the Federal government) who is liable for@;"
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| 54 | W !,"PU11.5,8.3;LBthe disease. For instance, manufacturer of a chemical to which@;"
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| 55 | W !,"PU11.5,8;LBan emoloyee was exposed might be considered a third party if@;"
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| 56 | W !,"PU11.5,7.7;LBimproper instructions were given by the manufacturer for use of@;"
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| 57 | W !,"PU11.5,7.4;LBthe chemical.@;"
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| 58 | W !,"PU.5,6.2;PD22,6.2;PU.5,5.8;SD1,277,2,1,4,9,5,0,6,2,7,23;LBEmploying Agency - Required Codes@;"
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| 59 | W !,"PU.5,5.7;PD22,5.7;PU.5,5.7;RA22,6.2;"
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| 60 | W !,"PU.5,5.2;LBBox a (Occupation Code), Box b (Type Code), Box c@;"
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| 61 | W !,"PU.5,4.8;LB(Source Code), OSHA Site Code@;PU11,5.2;LBOWCP Agency Code@;"
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| 62 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,4.4;LBThe Occupational Safety and Health Administration (OSHA)@;"
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| 63 | W !,"PU11,4.8;LBThis is a four digit (or four digit two letter) code used by@;"
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| 64 | W !,"PU11,4.5;LBOWCP to identify the employing agency. The proper code@;"
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| 65 | W !,"PU11,4.2;LBmay be obtained from your personnel or compensation office,@;"
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| 66 | W !,"PU.5,4.1;LBrequires all employing agencies to complete these items when@;"
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| 67 | W !,"PU11,3.9;LBor by contacting OWCP.@;"
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| 68 | W !,"PU.5,3.8;LBreporting an injury. The proper codes may be found in OSHA@;"
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| 69 | W !,"PU.5,3.5;LBBooklet 2014, Record Keeping and Reporting Guidelines.@;"
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| 70 | W !,"PU.5,3;PD22,3;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 71 | W !,"PU18.5,2.5;LBForm CA-2@;PU18.5,2.1;LBRev. Jan. 1997@;"
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| 72 | Q
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