Form CA-2a, Notice of Recurrence Instructions

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This form contains 112 fields organized into 46 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Accommodations/Adjustments after Original Injury and Details (Part 38)
Accommodation - No (Part 38) Combobox
Enter 'No' if after the original injury the agency did not make any accommodations or adjustments to the employee's regular duties due to injury-related limitations.
Accommodation - Yes (Part 38) Combobox
Enter 'Yes' if after the original injury the agency made accommodations or adjustments to the employee's regular duties due to injury-related limitations.
Details of accommodations or adjustments (Part 38) Text
Provide a full, detailed description of any accommodations or adjustments made to the employee's regular duties after the original injury, including what was changed, duration, and any restrictions or limitations. Fill only if 'Accommodation - Yes (Part 38)' is 'Yes'.
Depends on: Accommodation - Yes (Part 38)
Additional Information
form1[0].Page3[0].item5RadioButtonList[0]_0 ComboBox
Select this option if applicable.
form1[0].Page3[0].item5RadioButtonList[0]_1 ComboBox
Select this option if applicable.
form1[0].Page3[0].item5RadioButtonList[1]_0 ComboBox
Select this option if applicable.
Agency Authorized Treatment on Form CA-16 (Part 37)
Agency authorized treatment (Yes) Combobox
Enter 'Yes' to indicate the agency authorized medical treatment on Form CA-16 at the time of the injury.
Agency authorized treatment (No) Combobox
Enter 'No' to indicate the agency did not authorize medical treatment on Form CA-16 at the time of the injury.
Compensation Information
If you claimed compensation for lost wages, for what period? Enter end date here in the format MM/DD/YYYY or select from the calendar by using the down arrow key Text
If you claimed compensation for lost wages, enter the end date of the period for which you are claiming compensation in the format MM/DD/YYYY or select from the calendar.
Condition since return to work (20)
Condition since return to work Text
Describe your medical condition since you returned to work, including the nature of the condition, any symptoms, how often they occur, and the medical treatment you have received (type and frequency).
Date (employee signature section) (24)
Date (Employee signature) Date
Enter the date the employee signed the form.
Date and Hour of original injury (11)
Original injury date Date
Enter the calendar date when the original injury occurred.
Original injury time Time
Enter the time of day when the original injury occurred.
Date and Hour of recurrence (12)
Hour of recurrence Time
Enter the time of day when the recurrence occurred.
Date of recurrence Date
Enter the calendar date when the recurrence occurred.
Date and Hour pay stopped after recurrence (14)
Hour pay stopped after recurrence Time
Enter the time of day when your pay stopped as a result of the recurrence. Fill only if 'Time Loss From Work' Fill only if Time Loss From Work is 'Yes'.
Depends on: Time Loss From Work
Date pay stopped after recurrence Date
Enter the date on which your pay stopped as a result of the recurrence. Fill only if 'Time Loss From Work' Fill only if Time Loss From Work is 'Yes'.
Depends on: Time Loss From Work
Date and Hour returned to work (15)
Hour returned to work Time
Enter the time of day you returned to work after the recurrence. Fill only if 'Time Loss From Work' Fill only if Time Loss From Work is 'Yes'.
Depends on: Time Loss From Work
Date returned to work Date
Enter the date you returned to work after the recurrence. Fill only if 'Time Loss From Work' Fill only if Time Loss From Work is 'Yes'.
Depends on: Time Loss From Work
Date and Hour stopped work after recurrence (13)
Hour stopped work after recurrence Time
Enter the clock time when you stopped working because of the recurrence. Fill only if 'Time Loss From Work' Fill only if Time Loss From Work is 'Yes'.
Depends on: Time Loss From Work
Date stopped work after recurrence Date
Enter the date when you stopped working because of the recurrence. Fill only if 'Time Loss From Work' Fill only if Time Loss From Work is 'Yes'.
Depends on: Time Loss From Work
Date of first medical treatment following recurrence (17)
Date of first medical treatment following recurrence Date
Enter the date when you first received medical treatment for the recurrence of your injury. Fill only if 'Medical Treatment' Fill only if Medical Treatment is 'Yes'.
Depends on: Medical Treatment
Date of first return to FULL-TIME REGULAR duty (Part 27)
Date of first return to full-time regular duty Date
Enter the date when the employee first returned to full-time regular duty following the original injury.
Date of Injury (Part 30)
Date of injury (Part 30) Date
Enter the date on which the injury occurred.
Date of Recurrence (Part 31)
Date of recurrence Date
Enter the date when the medical condition or injury recurred following the original incident.
Date Pay Stopped after Recurrence (Part 33)
Date pay stopped after recurrence Date
Enter the date when the employee's pay stopped following the recurrence.
Date Returned to Work after Recurrence (Part 35)
Time Returned to Work (after recurrence) Time
Enter the clock time when the employee returned to work following the recurrence of the work-related condition.
Date Returned to Work (after recurrence) Date
Enter the calendar date when the employee returned to work following the recurrence of the work-related condition.
Date Stopped Work after Recurrence (Part 32)
Date Stopped Work After Recurrence Date
Enter the date on which the employee stopped work as a result of the recurrence of the injury.
Time Stopped Work After Recurrence Time
Enter the time of day when the employee stopped work due to the recurrence of the injury.
Dates COP Paid for Recurrence (Part 34)
COP Paid From (recurrence) Date
Enter the date on which continuation of pay (COP) for the recurrence began.
COP Paid To (recurrence) Date
Enter the date on which continuation of pay (COP) for the recurrence ended.
Dependents
Spouse Checkbox
Check this box if your dependent is your spouse.
Child/Children under 18 years Checkbox
Check this box if your dependent is a child (or children) under 18 years of age.
Other, e.g., qualifying student under age 23 Checkbox
Check this box for other dependents such as a qualifying student under age 23 or other eligible dependent not covered by the previous boxes.
Educational and Vocational Training
Describe all educational and/or vocational training received since your original injury. Include any licenses or certificates earned Text
Describe all educational and/or vocational training you have received since your original injury. Include any licenses or certificates earned.
Employee Information
Enter the date this form was signed by employee in the format MM/DD/YYYY or select from the calendar by using the down arrow key Text
Enter the date this form was signed by the employee in the format MM/DD/YYYY or select from the calendar.
Employee Name
Last Name Text
Enter the employee's family or last name (surname) as it appears on official records.
First Name Text
Enter the employee's given or first name exactly as used on official documents.
Middle Initial Text
Enter the employee's middle initial (single letter) or leave blank if none.
Employee's Duty Station Address (Part 26)
Duty Station ZIP Code Text
Enter the ZIP or postal code for the employee's duty station.
Duty Station State Combobox
Enter the U.S. state or jurisdiction for the duty station (use the standard two-letter abbreviation if applicable).
AR WV MO OK UT VA NJ VI GA DC DE FM ME PW MH OH RI NV ID PA SC NC IN LA MS TX CA WA MD GU WY PR AZ OR TN NH MI CT KS KY NY CO MN AK ND NM VT WI AL MT NE MP HI IA IL AS FL MA SD
Duty Station City Text
Enter the city or town where the employee's duty station is located.
Duty Station Address — Additional Line Text
Enter any additional address details for the duty station such as suite, floor, building name, or P.O. box.
Duty Station Address — Street Line 2 Text
Enter a second street address line for the duty station (for example, apartment, suite, or unit number) if needed.
Duty Station Address — Street Line 1 Text
Enter the primary street address of the employee's duty station, including number and street name.
Employing Agency at time of original injury
ZIP code Text
Enter the ZIP code for the employing agency's address (5-digit ZIP or ZIP+4).
State Combobox
Enter the state where the employing agency is located (use the two-letter postal abbreviation or full state name).
AR WV MO OK UT VA NJ VI GA DC DE FM ME PW MH OH RI NV ID PA SC NC IN LA MS TX CA WA MD GU WY PR AZ OR TN NH MI CT KS KY NY CO MN AK ND NM VT WI AL MT NE MP HI IA IL AS FL MA SD
Employing agency street address Text
Enter the agency's street address including building number, street name and apartment or suite number if applicable.
Employing agency name Text
Enter the full name of the employing agency or department that employed you at the time of the original injury.
City Text
Enter the city where the employing agency's address is located.
Employing Agency at time of recurrence
ZIP code (agency at recurrence) Text
Enter the ZIP code for the employing agency's address at the time of the recurrence. Fill only if 'Employing agency name' Fill only if Name and Address of Employing Agency at time of recurrence is other than shown in 9.
Depends on: Employing agency name
State (agency at recurrence) Combobox
Enter the state where the employing agency was located at the time of the recurrence (use the state name or postal abbreviation). Fill only if 'Employing agency name' Fill only if Name and Address of Employing Agency at time of recurrence is other than shown in 9.
AR WV MO OK UT VA NJ VI GA DC DE FM ME PW MH OH RI NV ID PA SC NC IN LA MS TX CA WA MD GU WY PR AZ OR TN NH MI CT KS KY NY CO MN AK ND NM VT WI AL MT NE MP HI IA IL AS FL MA SD
Depends on: Employing agency name
City (agency at recurrence) Text
Enter the city where the employing agency was located at the time of the recurrence. Fill only if 'Employing agency name' Fill only if Name and Address of Employing Agency at time of recurrence is other than shown in 9.
Depends on: Employing agency name
Agency street address (at recurrence) Text
Enter the agency's street address at the time of the recurrence, including building, suite, or room number as needed (do not repeat city, state, or ZIP). Fill only if 'Employing agency name' Fill only if Name and Address of Employing Agency at time of recurrence is other than shown in 9.
Depends on: Employing agency name
Employing agency name (at recurrence) Text
Enter the full name of the employing agency or office at the time of the recurrence, including department or division if applicable. Fill only if 'Employing agency name' Fill only if Name and Address of Employing Agency at time of recurrence is other than shown in 9.
Depends on: Employing agency name
Employment History
Part C. Employee. To be completed by the employee if not employed with the Federal Government at the time of the claimed recurrence. For all jobs held since you left the job held when the initial injury occurred, list the full name and address of your employers, and the inclusive dates of employment. Include any self-employment Text
If you are not employed with the Federal Government at the time of the claimed recurrence, list the full name and address of all employers and the inclusive dates of employment for all jobs held since you left the job held when the initial injury occurred. Include any self-employment.
For all jobs listed in item 1 above, provide your job title, nature of duties performed, number of hours worked per week and rate of pay Text
For all jobs listed in the previous field, provide your job title, nature of duties performed, number of hours worked per week, and rate of pay.
Form Actions
Print form Button
Click this button to print the form.
Reset form Button
Click this button to reset the form to its default state.
Home Mailing Address
Street Address Text
Enter your home street mailing address including house number and street name and any apartment or unit number.
City Text
Enter the city for your home mailing address.
State Combobox
Enter the state for your home mailing address (use the standard two-letter abbreviation if applicable).
AR WV MO OK UT VA NJ VI GA DC DE FM ME PW MH OH RI NV ID PA SC NC IN LA MS TX CA WA MD GU WY PR AZ OR TN NH MI CT KS KY NY CO MN AK ND NM VT WI AL MT NE MP HI IA IL AS FL MA SD
ZIP Code Text
Enter the postal ZIP code for your home mailing address (ZIP or ZIP+4).
How and when the recurrence happened (21)
How and when the recurrence happened Text
Describe in your own words when and how the medical recurrence occurred and explain why you believe the current condition is related to the original injury.
Identification Numbers (SSN, OWCP file)
Social Security Number Text
Enter the employee's Social Security Number as shown on their records.
OWCP File Number (Original Injury) Text
Enter the Office of Workers' Compensation Programs (OWCP) file number assigned to the original injury claim.
Injuries/illnesses between return and recurrence (22)
Injuries/Illnesses Between Return and Recurrence Text
Enter a detailed list of all injuries and illnesses you experienced between the date you returned to work after the original injury and the date of recurrence, including dates, brief descriptions of each condition, and any relevant treatment or medical providers (attach or arrange submission of supporting medical records).
Limitations after returning to work (19)
form1[0].Page1[0].item19RadioButtonList[0]_0 Combobox
This field appears to be a radio button with no clear label or options. Please refer to the form for more details.
form1[0].Page1[0].item19RadioButtonList[0]_1 Combobox
Select this option if you have experienced a recurrence of your work-related injury or condition.
Limitations After Returning to Work (Question 19) Text
Describe any ways you were limited in performing your usual job duties after returning to work following the original injury, including what limitations occurred, how they affected your work, and how long those limitations continued. Fill only if 'form1[0].Page1[0].item19RadioButtonList[0]_1' Fill only if After returning to work following the original injury, were you in any way limited in performing your usual duties? is 'Yes'.
Depends on: form1[0].Page1[0].item19RadioButtonList[0]_1
Medical Care at Agency Facility for Recurrence (Part 36)
Received medical care at agency facility - Yes Combobox
Enter 'Yes' if the employee received medical care at an agency facility due to the recurrence and attach all relevant medical records.
Received medical care at agency facility - No Combobox
Enter 'No' if the employee did not receive medical care at an agency facility due to the recurrence.
Other Injury/Illness After Return to Work (Details) (Part 39)
Details of other injury/illness after return to work Text
Describe any injury or illness the employee sustained after returning to work that affected performance of duties, including when it occurred, how it happened, body part(s) involved, symptoms, treatment received, and any effect on work duties.
Pay Information
What was your rate of pay if you stopped work due to this recurrence? Enter amount here Text
Enter your rate of pay if you stopped work due to this recurrence.
What was your rate of pay if you stopped work due to this recurrence? Enter per here Text
Enter the period (e.g., per hour, per week) for your rate of pay if you stopped work due to this recurrence.
If you received any pay during the period claimed, how much and from what source? Enter amount here Text
If you received any pay during the period claimed, enter the amount here.
If you received any pay during the period claimed, how much and from what source? Enter source here Text
If you received any pay during the period claimed, enter the source of the pay here.
Personal Details (Date of Birth, Sex, Home Telephone)
Date of Birth Date
Enter the employee's date of birth.
Sex — Male Combobox
Type 'Male' here if the employee's sex is male; otherwise leave this field blank.
Sex — Female Combobox
Type 'Female' here if the employee's sex is female; otherwise leave this field blank.
Home Telephone Text
Enter the employee's home telephone number including area code and extension if applicable.
Recurrence Information
form1[0].Page3[0].item5RadioButtonList[1]_1 ComboBox
Select whether the employee has experienced a recurrence of a work-related injury or condition.
Regular Work Days (Part 29)
Sun. Checkbox
Check this box if the employee regularly works on Sunday as one of their regular work days.
Mon. Checkbox
Check this box if the employee regularly works on Monday as one of their regular work days.
Tues. Checkbox
Check this box if the employee regularly works on Tuesday as one of their regular work days.
Wed. Checkbox
Check this box if the employee regularly works on Wednesday as one of their regular work days.
Thurs. Checkbox
Check this box if the employee regularly works on Thursday as one of their regular work days.
Fri. Checkbox
Check this box if the employee regularly works on Friday as one of their regular work days.
Sat. Checkbox
Check this box if the employee regularly works on Saturday as one of their regular work days.
Regular Work Hours (From/To) (Part 28)
Regular Work Hours - From Time
Enter the employee's regular start time for their work day (the time they normally begin work).
Regular Work Hours - To Time
Enter the employee's regular end time for their work day (the time they normally finish work).
Reporting Office Name and Address (Part 25)
Reporting Office Name Text
Enter the official name of the reporting office or agency (for example, the branch, division, or unit responsible for this report).
OWCP Agency Code Text
Enter the OWCP (Office of Workers' Compensation Programs) agency code assigned to this reporting office.
ZIP Code Text
Enter the ZIP code for the reporting office's mailing address.
State Combobox
Enter the state where the reporting office is located (use the two-letter abbreviation or full state name).
AR WV MO OK UT VA NJ VI GA DC DE FM ME PW MH OH RI NV ID PA SC NC IN LA MS TX CA WA MD GU WY PR AZ OR TN NH MI CT KS KY NY CO MN AK ND NM VT WI AL MT NE MP HI IA IL AS FL MA SD
City Text
Enter the city where the reporting office is located.
Street Address Line 2 Text
Enter additional street address information such as suite, room, building, floor, or P.O. Box for the reporting office.
Street Address Line 1 Text
Enter the primary street address of the reporting office (street number and name).
OSHA Site Code Text
Enter the OSHA site code for this reporting location if one has been assigned; leave blank if not applicable.
Review of Employee Statements / Additional Comments (Part 40)
Reviewer comments (Part 40) Text
Enter any relevant comments, clarifications, or additional information reviewing the employee's statements from Part A of the form; include specifics, dates, names, or explanations that support or amend the employee's account.
Signature Information
Enter the date this form was signed by employee in the format MM/DD/YYYY or select from the calendar by using the down arrow key Text
Enter the date this form was signed by the employee in the format MM/DD/YYYY or select from the calendar using the down arrow key.
Supervisor/Compensation Specialist - Title, Work Phone, Date (Parts 41-44)
Supervisor/Compensation Specialist Title Text
Enter the job title of the supervisor or compensation specialist who is signing or certifying this form.
Date of Signature Date
Enter the date when the supervisor or compensation specialist signed or certified this form.
Work Phone Text
Provide the work telephone number for the supervisor or compensation specialist, including area code and any extension if applicable.
Treating physician name and address (18)
Treating physician ZIP code Text
Enter the ZIP code for the treating physician's office (include ZIP+4 if available). Fill only if 'Medical Treatment' Fill only if Medical Treatment is 'Yes'.
Depends on: Medical Treatment
Treating physician State Combobox
Enter the U.S. state or territory where the treating physician's office is located. Fill only if 'Medical Treatment' Fill only if Medical Treatment is 'Yes'.
AR WV MO OK UT VA NJ VI GA DC DE FM ME PW MH OH RI NV ID PA SC NC IN LA MS TX CA WA MD GU WY PR AZ OR TN NH MI CT KS KY NY CO MN AK ND NM VT WI AL MT NE MP HI IA IL AS FL MA SD
Depends on: Medical Treatment
Treating physician City Text
Enter the city where the treating physician's office is located. Fill only if 'Medical Treatment' Fill only if Medical Treatment is 'Yes'.
Depends on: Medical Treatment
Treating physician street address Text
Enter the treating physician's mailing street address, including suite or room number if applicable. Fill only if 'Medical Treatment' Fill only if Medical Treatment is 'Yes'.
Depends on: Medical Treatment
Treating physician name Text
Enter the full name of the treating physician (e.g., Dr. First Last or Last, First Middle initial). Fill only if 'Medical Treatment' Fill only if Medical Treatment is 'Yes'.
Depends on: Medical Treatment
Type of claim (Medical Treatment / Time Loss) (16)
Time Loss From Work Checkbox
Check this box if you are claiming or seeking compensation for time lost from work due to the recurrence.
Medical Treatment Checkbox
Check this box if you are claiming or seeking compensation for medical treatment related to the recurrence.