Form CA-2a, Notice of Recurrence Instructions
This form contains 112 fields organized into 24 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| form1[0].Page3[0].item5RadioButtonList[0]_0 | ComboBox |
Select this option if applicable.
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| form1[0].Page3[0].item5RadioButtonList[0]_1 | ComboBox |
Select this option if applicable.
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| form1[0].Page3[0].item5RadioButtonList[1]_0 | ComboBox |
Select this option if applicable.
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| Claim Information | ||
| Check here if you are claiming time loss from work | CheckBox |
Check this box if you are claiming time loss from work due to the recurrence of your injury or condition.
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| What are you claiming? Check both boxes if applicable. Check here if you are claiming Medical Treatment | CheckBox |
Check this box if you are claiming medical treatment due to the recurrence of your injury or condition. You can check both boxes if applicable.
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| 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.
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| Dependents | ||
| Dependents. Select here for spouse | CheckBox |
Check this box if the employee has a spouse as a dependent.
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| Dependents. Select here for child/children under 18 years | CheckBox |
Check this box if the employee has children under 18 years old as dependents.
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| Dependents. Select here for other, for example, qualifying student under age 23 | CheckBox |
Check this box if the employee has other dependents, such as a qualifying student under age 23.
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| Duty Station Information | ||
| Enter the duty station's zip code | Text |
Enter the ZIP code of the duty station.
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| Select duty station's state from the drop-down menu | ComboBox |
Select the state of the duty station from the drop-down menu.
AR
WV
MO
OK
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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
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| Enter city of duty station | Text |
Enter the city of the duty station.
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| Enter street address of duty station | Text |
Enter the street address of the duty station.
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| Enter street address of duty station | Text |
Enter the street address of the duty station.
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| Employee's duty station (include street address, city, state, and ZIP Code). Enter duty station name here | Text |
Enter the name of the duty station, including street address, city, state, and ZIP Code.
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| 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.
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| Employee Address | ||
| Home mailing address (include street address, city, state, and ZIP code). See instructions for address requirement. Enter the street name of the employee's home mailing address | Text |
Enter the street name of the employee's home mailing address.
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| Enter the city name of the employee's home mailing address | Text |
Enter the city name of the employee's home mailing address.
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| Employee Information | ||
| Notice of Recurrence. U.S. Department of Labor. Office of Workers' Compensation Programs. DOL seal. Employee: Complete Part A below if you experienced a recurrence as defined by OWCP on page 4 of this form. Employing Agency (Supervisor or Compensation Specialist): Complete Part B. Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. OMB No. 1240-0009. Expires: XX-XX-XXXX. Name of employee (Last, First, Middle). Enter the employee's last name | Text |
Enter the employee's last name.
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| Enter the employee's first name | Text |
Enter the employee's first name.
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| Enter the employee's middle initial | Text |
Enter the employee's middle initial.
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| Enter employee's social security number | Text |
Enter the employee's social security number.
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| Enter the employee's date of birth in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the employee's date of birth in the format MM/DD/YYYY or select from the calendar by using the down arrow key.
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| form1[0].Page1[0].item5sex[0]_0 | ComboBox |
Select this option if the employee is male.
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| form1[0].Page1[0].item5sex[0]_1 | ComboBox |
Select this option if the employee is female.
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| Enter the employee's phone number, area code first. For example, 2224441111 | Text |
Enter the employee's phone number, area code first. For example, 2224441111.
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| Select the employee's home mailing address state from the drop-down menu | ComboBox |
Select the state of the employee's home mailing address from the provided drop-down menu.
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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
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| Enter the employee's home mailing address zip code | Text |
Enter the zip code of the employee's home mailing address.
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| Enter the date pay stopped after recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date when your pay stopped after the recurrence of your work-related injury or condition. Use the format MM/DD/YYYY or select the date from the calendar.
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| Enter the hour returned to work in the format HH:MM AM/PM | Text |
Enter the exact hour you returned to work after the recurrence of your injury or condition. Use the format HH:MM AM/PM.
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| Enter the date returned to work in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date when you returned to work after the recurrence of your work-related injury or condition. Use the format MM/DD/YYYY or select the date from the calendar.
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| form1[0].Page1[0].item19RadioButtonList[0]_1 | ComboBox |
Select this option if you have experienced a recurrence of your work-related injury or condition.
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| If, after returning to work following the original injury, you were in any way limited in performing your usual duties, state here how long these limitations continued | Text |
Provide details on any limitations you experienced in performing your usual duties after returning to work following the original injury, including the duration of these limitations.
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| Enter the date employee signed this document, in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date you signed this document in the format MM/DD/YYYY or select the date from the calendar.
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| Enter date of first return to FULL-TIME REGULAR duty following original injury, in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date of your first return to full-time regular duty following the original injury, in the format MM/DD/YYYY or select from the calendar.
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| Enter your regular work hours. Put the start time here in the format HH:MM AM/PM | Text |
Enter your regular work hours. Put the start time here in the format HH:MM AM/PM.
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| Enter your regular work hours. Put the end time here in the format HH:MM AM/PM | Text |
Enter your regular work hours. Put the end time here in the format HH:MM AM/PM.
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| Select your regular work days. Select here for Sunday | CheckBox |
Select your regular work days. Check this box if you work on Sunday.
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| Enter the date returned to work after recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date you returned to work after the recurrence of your injury. Use the format MM/DD/YYYY or select the date from the calendar.
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| form1[0].Page2[0].item36RadioButtonList[0]_0 | ComboBox |
Select this option if the employee has returned to work after the recurrence.
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| form1[0].Page2[0].item36RadioButtonList[0]_1 | ComboBox |
Select this option if the employee has not returned to work after the recurrence.
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| form1[0].Page2[0].item38RadioButtonList[0]_0 | ComboBox |
Select this option if any accommodations or adjustments were made to the employee's regular duties due to injury-related limitations.
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| form1[0].Page2[0].item38RadioButtonList[0]_1 | ComboBox |
Select this option if no accommodations or adjustments were made to the employee's regular duties due to injury-related limitations.
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| If after the original injury, you made any accommodations or adjustments in the employee's regular duties due to injury-related limitation, enter details here | Text |
If any accommodations or adjustments were made to the employee's regular duties due to injury-related limitations, enter the details here.
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| After return to work, did the employee sustain any other injury or illness which affected performance of his or her duties? If so, enter full details here | Text |
If the employee sustained any other injury or illness after returning to work that affected their performance, enter the full details here.
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| Please review the statements made by the employee in Part A of this form and enter any relevant comments and additional information here | Text |
Review the statements made by the employee in Part A of this form and enter any relevant comments or additional information here.
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| 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.
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| Employing Agency Information | ||
| Enter the employing agency's zip code | Text |
Enter the zip code of the employing agency.
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| Select employing agency's state from the drop-down menu | ComboBox |
Select the state of the employing agency from the provided drop-down menu.
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
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| Enter employing agency street address | Text |
Enter the street address of the employing agency.
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| Enter city of employing agency | Text |
Enter the city of the employing agency.
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| Enter the employing agency's zip code | Text |
Enter the zip code of the employing agency.
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| Select the employing agency's state from the drop-down menu | ComboBox |
Select the state of the employing agency from the provided drop-down menu.
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
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| Enter the employing agency's city name | Text |
Enter the city name of the employing agency.
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| Enter employing agency street address | Text |
Enter the street address of the employing agency.
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| Name and Address of Employing Agency at time of recurrence, if other than shown in 9. If you are no longer employed with the Federal Government, complete Part C also. Enter employing agency name | Text |
Enter the name and address of the employing agency at the time of recurrence. If different from the previously provided information, and if no longer employed with the Federal Government, complete Part C as well.
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| Part B. Federal Employing Agency. Name and address of reporting office (include street address, city, state and ZIP Code). Enter name of reporting office here | Text |
Enter the name and address of the reporting office, including street address, city, state, and ZIP Code.
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| Enter OWCP Agency Code | Text |
Enter the OWCP Agency Code for the reporting office.
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| Enter the reporting office's zip code | Text |
Enter the ZIP Code of the reporting office.
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| Select reporting office's state from the drop-down menu | ComboBox |
Select the state of the reporting office from the drop-down menu.
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
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| Enter city of reporting office | Text |
Enter the city of the reporting office.
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| A supervisor or compensation specialist who knowingly certifies to any false statement, misrepresentation, concealment of fact, etc., in respect to this claim may also be subject to appropriate criminal prosecution. Signature of Supervisor or Compensation Specialist (at time of recurrence). Enter title here | Text |
Enter the title of the supervisor or compensation specialist who is signing this form at the time of the recurrence.
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| Enter the date this form was signed 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. Use the format MM/DD/YYYY or select the date from the calendar.
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| 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.
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| 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.
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| Form Actions | ||
| Print form | Button |
Click this button to print the form.
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| Reset form | Button |
Click this button to reset the form to its default state.
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| Injury Details | ||
| Enter the date of injury in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date of the original injury in the format MM/DD/YYYY or select from the calendar using the down arrow key.
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| Medical Information | ||
| Describe your condition since you returned to work, including the nature and frequency of all medical treatment received | Text |
Describe your condition since returning to work, including the nature and frequency of all medical treatments you have received.
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| Describe all injuries and illnesses which you suffered between the date you returned to work after the original injury, and the date of recurrence. Arrange for the submission of all relevant medical records | Text |
List all injuries and illnesses you have suffered between the date you returned to work after the original injury and the date of recurrence. Ensure all relevant medical records are submitted.
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| Medical Treatment | ||
| Enter the date of first medical treatment following recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date of your first medical treatment following the recurrence of your work-related injury or condition. Use the format MM/DD/YYYY or select the date from the calendar.
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| Enter the zip code of the treating physician | Text |
Enter the zip code of the physician who treated you for the recurrence of your injury or condition.
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| Select the treating physician's state from the drop-down menu | ComboBox |
Select the state where your treating physician is located from the drop-down menu.
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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
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| Enter city of treating physician | Text |
Enter the city where your treating physician is located.
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| Enter street address of treating physician | Text |
Enter the street address of your treating physician.
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| Enter name of treating physician | Text |
Enter the name of the physician who treated you for the recurrence of your injury or condition.
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| form1[0].Page2[0].item37RadioButtonList[0]_0 | ComboBox |
Select this option if the employee is currently receiving medical treatment for the recurrence.
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| form1[0].Page2[0].item37RadioButtonList[0]_1 | ComboBox |
Select this option if the employee is not currently receiving medical treatment for the recurrence.
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| Original Injury Information | ||
| Enter employee's OWCP file number for original injury | Text |
Enter the employee's OWCP file number for the original injury.
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| Name and Address of Employing Agency at time of original injury (number, street, city, state, ZIP code). Enter name of employing agency | Text |
Enter the name and address of the employing agency at the time of the original injury, including number, street, city, state, and ZIP code.
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| Enter the date of original injury in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date of the original injury in the format MM/DD/YYYY or select it from the calendar.
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| Enter the hour of original injury in the format HH:MM AM/PM | Text |
Enter the hour of the original injury in the format HH:MM AM/PM.
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| Pay Details | ||
| Dates COP paid for recurrence. Enter from date in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the start date for the Continuation of Pay (COP) period for the recurrence in the format MM/DD/YYYY or select from the calendar using the down arrow key.
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| Dates COP paid for recurrence. Enter to date in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the end date for the Continuation of Pay (COP) period for the recurrence in the format MM/DD/YYYY or select from the calendar using the down arrow key.
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| 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.
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| 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.
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| 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.
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| 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.
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| Recurrence Details | ||
| Describe how and when the recurrence happened. Explain why you believe your current condition is related to the original injury | Text |
Explain how and when the recurrence of your injury or condition happened, and why you believe it is related to the original injury.
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| Enter the date of recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date of the recurrence of the injury in the format MM/DD/YYYY or select from the calendar using the down arrow key.
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| Enter the date stopped work after recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date you stopped working after the recurrence in the format MM/DD/YYYY or select from the calendar using the down arrow key.
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| Enter the time on the day work stopped after recurrence in the format HH:MM AM/PM | Text |
Enter the time on the day you stopped working after the recurrence in the format HH:MM AM/PM.
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| Enter the date pay stopped after recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date your pay stopped after the recurrence in the format MM/DD/YYYY or select from the calendar using the down arrow key.
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| Enter the time returned to work after recurrence in the format HH:MM AM/PM | Text |
Enter the time you returned to work after the recurrence in the format HH:MM AM/PM.
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| Recurrence Information | ||
| Enter the hour of recurrence in the format HH:MM AM/PM | Text |
Enter the hour of the recurrence in the format HH:MM AM/PM.
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| Enter the date of recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date of the recurrence in the format MM/DD/YYYY or select it from the calendar.
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| Enter the hour stopped work after recurrence in the format HH:MM AM/PM | Text |
Enter the hour you stopped work after the recurrence in the format HH:MM AM/PM.
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| Enter the date stopped work after recurrence in the format MM/DD/YYYY or select from the calendar by using the down arrow key | Text |
Enter the date you stopped work after the recurrence in the format MM/DD/YYYY or select it from the calendar.
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| Enter the hour pay stopped after recurrence in the format HH:MM AM/PM | Text |
Enter the hour your pay stopped after the recurrence in the format HH:MM AM/PM.
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| form1[0].Page3[0].item5RadioButtonList[1]_1 | ComboBox |
Select whether the employee has experienced a recurrence of a work-related injury or condition.
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| Reporting Office Information | ||
| Enter street address of reporting office | Text |
Enter the street address of the reporting office.
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| Enter street address of reporting office | Text |
Enter the street address of the reporting office.
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| Enter OSHA Site Code | Text |
Enter the OSHA Site Code for the reporting office.
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| 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.
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| Supervisor Information | ||
| Enter the supervisor's work phone number, area code first. For example, 2224441111 | Text |
Enter the work phone number of your supervisor, starting with the area code. For example, 2224441111.
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| Uncategorized | ||
| 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.
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| Work Schedule | ||
| Select your regular work days. Select here for Monday | CheckBox |
Select this checkbox if Monday is one of your regular work days.
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| Select your regular work days. Select here for Tuesday | CheckBox |
Select this checkbox if Tuesday is one of your regular work days.
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| Select your regular work days. Select here for Wednesday | CheckBox |
Select this checkbox if Wednesday is one of your regular work days.
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| Select your regular work days. Select here for Thursday | CheckBox |
Select this checkbox if Thursday is one of your regular work days.
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| Select your regular work days. Select here for Friday | CheckBox |
Select this checkbox if Friday is one of your regular work days.
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| Select your regular work days. Select here for Saturday | CheckBox |
Select this checkbox if Saturday is one of your regular work days.
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