Form CA-2, Notice of Occupational Disease Completed Form Examples and Samples
Explore detailed CA-2 form examples showcasing how to correctly fill out the Notice of Occupational Disease for different work-related ailments. These samples include key information like employee details, job title, supervisor contact, disease description, and workplace conditions.
CA-2 Example – Notice of Occupational Disease
How this form was filled:
This example shows a properly filled Form CA-2 for reporting an occupational disease due to repetitive motion in an office environment. Key fields include employee details, supervisor information, and a description of the occupational disease claim.
Information used to fill out the document:
- Employee's Name: Jane Smith
- Social Security Number: 123-45-6789
- Date of Birth: 03/15/1985
- Employee's Address: 456 Elm Street, Anytown, USA
- Job Title: Data Analyst
- Department: IT Department
- Supervisor's Name: Michael Brown
- Date Occupational Disease Noticed: 02/20/2025
- Description of Disease: Repetitive strain injury due to long hours of typing
- Workplace Conditions Description: Lack of ergonomic support
- Signature: Jane Smith
- Date Signed: 02/22/2025
What this filled form sample shows:
- Accurate employee details including personal and job-related information
- Precise description of occupational disease with relevant dates
- Details of supervisor information and workplace conditions
- Proper signature and date for validity
Form specifications and details:
| Use Case: | Reporting of a repetitive motion injury due to office work |
CA-2 Example – Notice of Occupational Disease: Noise-Induced Hearing Loss
How this form was filled:
This example illustrates a filled Form CA-2 for reporting an occupational disease related to noise-induced hearing loss experienced by a factory worker. Key fields include employee's information, supervisor details, and a description of the workplace conditions.
Information used to fill out the document:
- Employee's Name: John Doe
- Social Security Number: 987-65-4321
- Date of Birth: 05/22/1980
- Employee's Address: 789 Maple Street, Factoryville, USA
- Job Title: Assembly Line Worker
- Department: Manufacturing
- Supervisor's Name: Catherine Johnson
- Date Occupational Disease Noticed: 01/12/2025
- Description of Disease: Noise-induced hearing loss due to prolonged exposure to factory noise
- Workplace Conditions Description: High levels of continuous noise without adequate hearing protection
- Signature: John Doe
- Date Signed: 01/15/2025
What this filled form sample shows:
- Detailed employee information including personal, address, and job-related details
- Thorough disease description and identification of workplace noise conditions
- Inclusion of supervisor contact for official follow-up
- Validation through employee signature and date
Form specifications and details:
| Use Case: | Reporting of a hearing loss injury due to excessive noise in a manufacturing setting |
