Form CA-2, Notice of Occupational Disease Instructions
This form contains 102 fields organized into 28 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agency Information | ||
| Enter agency city | Text |
Enter the city where the agency is located.
|
| Choose agency state | ComboBox |
Select the state where the agency is located from the dropdown list.
KS
DE
MO
MS
NV
VI
TX
HI
MH
AL
OR
NH
VT
WI
AZ
GU
MT
NE
RI
MD
SC
ME
ID
PR
NJ
CT
GA
TN
WY
PA
DC
UT
CA
OK
FL
AK
KY
IL
NC
IA
PW
VA
WA
WV
FM
AR
MN
MA
LA
SD
NM
OH
ND
MI
NY
MP
AS
CO
IN
|
| Enter agency zip code | Text |
Enter the zip code of the agency where the employee works.
|
| Dependents | ||
| Wife_Husband | CheckBox |
Check this box if the employee has a spouse (wife or husband).
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| Select dependents. Select here for children under 18 years | CheckBox |
Check this box if the employee has children under 18 years old.
|
| Select dependents. Select here for other | CheckBox |
Check this box if the employee has other dependents not listed.
|
| Disease Information | ||
| Enter date you first became aware of disease or illness (MM/DD/YYYY) | Text |
Enter the date you first became aware of the disease or illness in the format MM/DD/YYYY.
|
| Enter date you first realized the disease or illness was caused or aggravated by your employment (MM/DD/YYYY) | Text |
Enter the date you first realized that the disease or illness was caused or aggravated by your employment in the format MM/DD/YYYY.
|
| Disease/Illness Details | ||
| Explain the relationship to your employment, and why you came to this realization | Text |
Explain how the disease or illness is related to the employee's employment and why the employee believes this to be the case.
|
| Enter the nature of disease or illness | Text |
Enter the nature of the disease or illness the employee is suffering from.
|
| Duty Station Information | ||
| Enter duty station zip code | Text |
Enter the zip code of the duty station where the employee is assigned.
|
| Employee Duty Station | ||
| Enter employee's duty station street address | Text |
Enter the street address of the employee's duty station. Maximum length is 55 characters.
|
| Enter employee's duty station city | Text |
Enter the city of the employee's duty station. Maximum length is 25 characters.
|
| Choose employee's duty station state | ComboBox |
Select the state of the employee's duty station from the dropdown list.
KS
DE
MO
MS
NV
VI
TX
HI
MH
AL
OR
NH
VT
WI
AZ
GU
MT
NE
RI
MD
SC
ME
ID
PR
NJ
CT
GA
TN
WY
PA
DC
UT
CA
OK
FL
AK
KY
IL
NC
IA
PW
VA
WA
WV
FM
AR
MN
MA
LA
SD
NM
OH
ND
MI
NY
MP
AS
CO
IN
|
| Employee Information | ||
| Enter employee's last name | Text |
Enter the employee's last name.
|
| Enter employee's first name | Text |
Enter the employee's first name.
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| Enter employee's middle initial | Text |
Enter the employee's middle initial. Only one character is allowed.
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| Select gender: Male; Female; Transgender; Non-Binary | ComboBox |
Select the employee's gender from the available options: Male, Female, Transgender, Non-Binary.
1
Female
Male
0
|
| Enter home telephone number | Text |
Enter the employee's home telephone number.
|
| Enter employee's home mailing address. Enter street address here | Text |
Enter the employee's home mailing address, specifically the street address.
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| Enter employee's home mailing address. Enter city here | Text |
Enter the city of the employee's home mailing address. Maximum length is 30 characters.
|
| Enter name of injured employee | Text |
Enter the full name of the injured employee.
|
| Employee Personal Information | ||
| Enter employee's home mailing address. Select state here | ComboBox |
Select the state of the employee's home mailing address from the provided list.
KS
DE
MO
MS
NV
VI
TX
HI
MH
AL
OR
NH
VT
WI
AZ
GU
MT
NE
RI
MD
SC
ME
ID
PR
NJ
CT
GA
TN
WY
PA
DC
UT
CA
OK
FL
AK
KY
IL
NC
IA
PW
VA
WA
WV
FM
AR
MN
MA
LA
SD
NM
OH
ND
MI
NY
MP
AS
CO
IN
|
| Enter employee's home mailing address. Enter zip code here | Text |
Enter the zip code of the employee's home mailing address.
|
| Enter employee's occupation | Text |
Enter the employee's current occupation.
|
| Enter occupation code | Text |
Enter the occupation code corresponding to the employee's current occupation.
|
| Employee Retirement Coverage | ||
| Employee's Retirement Coverage. Select here for CSRS | CheckBox |
Select this checkbox if the employee's retirement coverage is under the Civil Service Retirement System (CSRS).
|
| Employee's Retirement Coverage. Select here for FERS | CheckBox |
Select this checkbox if the employee's retirement coverage is under the Federal Employees Retirement System (FERS).
|
| Employee's Retirement Coverage. Select here for other | CheckBox |
Select this checkbox if the employee's retirement coverage is under a system other than CSRS or FERS.
|
| Enter Employee's Retirement Coverage | Text |
Enter the specific details of the employee's retirement coverage if it is not under CSRS or FERS.
|
| Employee Work Details | ||
| Enter hour employee stopped work | Text |
Enter the exact hour when the employee stopped working due to the occupational disease or illness.
|
| Enter hour employee's pay stopped | Text |
Enter the exact hour when the employee's pay stopped due to the occupational disease or illness.
|
| Enter hour employee returned to work | Text |
Enter the exact hour when the employee returned to work after the occupational disease or illness.
|
| If employee has returned to work and work assignment has changed, describe new duties | Text |
If the employee has returned to work and their work assignment has changed, describe the new duties they are now performing.
|
| Employee Work Status | ||
| topmostSubform[0].Page2[0].Radio_Button16[0]_0 | ComboBox |
Select this option if the employee is disabled for work.
|
| topmostSubform[0].Page2[0].Radio_Button16[0]_1 | ComboBox |
Select this option if the employee is not disabled for work.
|
| topmostSubform[0].Page2[0].disabled_for_work[0]_0 | ComboBox |
Select this option if the employee is disabled for work.
|
| topmostSubform[0].Page2[0].disabled_for_work[0]_1 | ComboBox |
Select this option if the employee is not disabled for work.
|
| Employment Details | ||
| Enter grade as of date of last exposure. Enter level here | Text |
Enter the employee's grade level as of the date of last exposure.
|
| Enter grade as of date of last exposure. Enter step here | Text |
Enter the employee's grade step as of the date of last exposure.
|
| Employment Information | ||
| Location where you worked when disease or illness occurred. Enter zip code here | Text |
Enter the zip code of the location where you were working when the disease or illness occurred.
|
| Enter agency name | Text |
Enter the name of the agency where you are employed.
|
| Enter OWCP agency code | Text |
Enter the OWCP agency code. This code is used for internal tracking by the Office of Workers' Compensation Programs.
|
| Enter the agency's street address | Text |
Enter the street address of the agency where you are employed.
|
| Enter OHSA Site code | Text |
Enter the OHSA Site code. This code is used for tracking purposes by the Occupational Safety and Health Administration.
|
| Enter date employee stopped work(MM/DD/YYYY) | Text |
Enter the date when the employee stopped working due to the occupational disease or illness. Use the format MM/DD/YYYY.
|
| Enter date employee's pay stopped(MM/DD/YYYY) | Text |
Enter the date when the employee's pay stopped due to the occupational disease or illness. Use the format MM/DD/YYYY.
|
| Enter date employee returned to work(MM/DD/YYYY) | Text |
Enter the date when the employee returned to work after the occupational disease or illness. Use the format MM/DD/YYYY.
|
| Exposure Information | ||
| Enter date employee was last exposed to conditions alleged to have caused disease or illness (MM/DD/YYYY) | Text |
Enter the date when the employee was last exposed to the conditions that are alleged to have caused the disease or illness. Use the format MM/DD/YYYY.
|
| Enter date employee was last exposed to conditions alleged to have caused disease or illness (MM/DD/YYYY) | Text |
Enter the date when the employee was last exposed to the conditions that are alleged to have caused the disease or illness. Use the format MM/DD/YYYY.
|
| Filing Information | ||
| If this notice and claim was not filed with the employing agency within 30 days after date shown above in item #12, explain the reason for the delay | Text |
If you did not file this notice and claim with your employing agency within 30 days after the date shown in item #12, provide an explanation for the delay.
|
| If the statement requested in item I of the attached instructions is not submitted with this form, explain reason for delay | Text |
If you did not submit the statement requested in item I of the attached instructions with this form, provide an explanation for the delay.
|
| If the medical reports requested in item 2 of attached instructions are not submitted with this form, explain reason for delay | Text |
If you did not submit the medical reports requested in item 2 of the attached instructions with this form, provide an explanation for the delay.
|
| Form Controls | ||
| Reset | Button |
Click this button to reset the form to its default state.
|
| Button |
Click this button to print the form.
|
|
| Incident Details | ||
| Enter location | Text |
Provide the specific location where the occupational disease or illness occurred. This could be the building, room, or area where you were working when you were exposed to the conditions that led to your illness.
|
| Enter date you were first notified about this condition (MM/DD/YYYY) | Text |
Enter the date when you were first notified or became aware of the occupational disease or illness. Use the format MM/DD/YYYY.
|
| Incident Reporting | ||
| Enter date employee first reported condition to supervisor (MM/DD/YYYY) | Text |
Enter the date when the employee first reported the condition to their supervisor. Use the format MM/DD/YYYY.
|
| Medical Information | ||
| Enter name of physician | Text |
Enter the name of the physician who first provided medical care to the employee.
|
| Enter physician's street address | Text |
Enter the street address of the physician who first provided medical care to the employee.
|
| Enter physician's zip code | Text |
Enter the zip code of the physician who provided medical care to the employee.
|
| Enter date first medical care received(MM/DD/YYYY) | Text |
Enter the date when the employee first received medical care for the occupational disease or illness. Use the format MM/DD/YYYY.
|
| OWCP Use | ||
| OWCP Use - NOI Code. Enter type code | Text |
Enter the type code as specified by the Office of Workers' Compensation Programs (OWCP). This is for internal use only.
|
| OWCP Use - NOI Code. Enter source code | Text |
Enter the source code as specified by the Office of Workers' Compensation Programs (OWCP). This is for internal use only.
|
| Personal Information | ||
| Enter email address | Text |
Enter your email address for contact purposes.
|
| Enter Social Security Number | Text |
Enter your Social Security Number.
|
| Enter date of birth (MM/DD/YYYY) | Text |
Enter your date of birth in the format MM/DD/YYYY.
|
| Physician Information | ||
| Enter physician's city | Text |
Enter the city where the physician who treated the employee is located.
|
| Choose physician's state | ComboBox |
Select the state where the physician who treated the employee is located from the dropdown list.
KS
DE
MO
MS
NV
VI
TX
HI
MH
AL
OR
NH
VT
WI
AZ
GU
MT
NE
RI
MD
SC
ME
ID
PR
NJ
CT
GA
TN
WY
PA
DC
UT
CA
OK
FL
AK
KY
IL
NC
IA
PW
VA
WA
WV
FM
AR
MN
MA
LA
SD
NM
OH
ND
MI
NY
MP
AS
CO
IN
|
| Supervisor Certification | ||
| A supervisor who knowingly certifies to any false statement, misrepresentation, concealment of fact, etc., in respect to this claim may also be subject to appropriate felony criminal prosecution. I certify that the information given above and that furnished by the employee on the reverse of this form is true to the best of my knowledge with the following exception | Text |
Provide any exceptions to the certification that the information given by the supervisor and the employee is true to the best of their knowledge.
|
| Supervisor Information | ||
| Enter name of supervisor | Text |
Enter the full name of the supervisor who is completing this section of the form.
|
| Enter supervisor's title | Text |
Enter the title of the supervisor who is completing this section of the form.
|
| Enter supervisor's telephone number | Text |
Enter the telephone number of the supervisor who is completing this section of the form.
|
| Enter title of official superior | Text |
Enter the job title of your official superior or supervisor. This is the person who oversees your work and can provide information about your work conditions.
|
| Enter date of official superior signature (MM/DD/YYYY) | Text |
Enter the date when your official superior or supervisor signed the form. Use the format MM/DD/YYYY.
|
| Third Party Information | ||
| Enter Name of Third Party | Text |
Enter the name of the third party involved, if any.
|
| topmostSubform[0].Page2[0]._33_Was_injury_causedby_third_party[0]_0 | ComboBox |
Select this radio button if the injury was caused by a third party.
|
| topmostSubform[0].Page2[0]._33_Was_injury_causedby_third_party[0]_1 | ComboBox |
Select this radio button if the injury was not caused by a third party.
|
| Enter Street Address of third party | Text |
Enter the street address of the third party involved.
|
| Enter city of third party | Text |
Enter the city of the third party involved.
|
| Choose state of third party | ComboBox |
Choose the state of the third party involved from the provided list.
KS
DE
MO
MS
NV
VI
TX
HI
MH
AL
OR
NH
VT
WI
AZ
GU
MT
NE
RI
MD
SC
ME
ID
PR
NJ
CT
GA
TN
WY
PA
DC
UT
CA
OK
FL
AK
KY
IL
NC
IA
PW
VA
WA
WV
FM
AR
MN
MA
LA
SD
NM
OH
ND
MI
NY
MP
AS
CO
IN
|
| Enter third party's zip code | Text |
Enter the zip code of any third party involved in the claim.
|
| Unspecified | ||
| topmostSubform[0].Page2[0].Radio_Buttonsw1[0]_0 | ComboBox |
Select this option if applicable. (Specific context for this radio button is not provided in the field name.)
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| topmostSubform[0].Page2[0].Radio_Buttonsw1[0]_1 | ComboBox |
Select this option if applicable. (Specific context for this radio button is not provided in the field name.)
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| topmostSubform[0].Page2[0].Radio_Buttonps1[0]_0 | ComboBox |
Select this option if applicable. (Specific context for this radio button is not provided in the field name.)
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| topmostSubform[0].Page2[0].Radio_Buttonps1[0]_1 | ComboBox |
Select this option if applicable. (Specific context for this radio button is not provided in the field name.)
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| topmostSubform[0].Page2[0].Radio_Buttonrw1[0]_0 | ComboBox |
Select this option if applicable. (Specific context for this radio button is not provided in the field name.)
|
| topmostSubform[0].Page2[0].Radio_Buttonrw1[0]_1 | ComboBox |
Select this option if applicable. (Specific context for this radio button is not provided in the field name.)
|
| Work Location Information | ||
| Location where you worked when disease or illness occurred. Enter street address here | Text |
Enter the street address of the location where the employee was working when the disease or illness occurred.
|
| Location where you worked when disease or illness occurred. Enter city here | Text |
Enter the city of the location where the employee was working when the disease or illness occurred.
|
| Location where you worked when disease or illness occurred. Choose state here | ComboBox |
Select the state of the location where the employee was working when the disease or illness occurred from the provided list.
KS
DE
MO
MS
NV
VI
TX
HI
MH
AL
OR
NH
VT
WI
AZ
GU
MT
NE
RI
MD
SC
ME
ID
PR
NJ
CT
GA
TN
WY
PA
DC
UT
CA
OK
FL
AK
KY
IL
NC
IA
PW
VA
WA
WV
FM
AR
MN
MA
LA
SD
NM
OH
ND
MI
NY
MP
AS
CO
IN
|
| Work Schedule | ||
| Enter regular work hours from | Text |
Enter the start time of the employee's regular work hours.
|
| topmostSubform[0].Page2[0].Radio_Button14[0]_0 | ComboBox |
Select this radio button if applicable. No specific value is provided.
|
| topmostSubform[0].Page2[0].Radio_Button14[0]_1 | ComboBox |
Select this radio button if applicable. No specific value is provided.
|
| Enter regular work hours to | Text |
Enter the end time of the employee's regular work hours.
|
| Select regular work schedule. Select here for Sunday | CheckBox |
Check this box if the employee's regular work schedule includes Sunday.
|
| Select regular work schedule. Select here for Monday | CheckBox |
Check this box if the employee's regular work schedule includes Monday.
|
| Select regular work schedule. Select here for Tuesday | CheckBox |
Check this box if the employee's regular work schedule includes Tuesday.
|
| Select regular work schedule. Select here for Wednesday | CheckBox |
Check this box if the employee's regular work schedule includes Wednesday.
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| Select regular work schedule. Select here for Thursday | CheckBox |
Check this box if the employee's regular work schedule includes Thursday.
|
| Select regular work schedule. Select here for Friday | CheckBox |
Check this box if the employee's regular work schedule includes Friday.
|
| Select regular work schedule. Select here for Saturday | CheckBox |
Check this box if the employee's regular work schedule includes Saturday.
|