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Form

Description

ca-1.pdf Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
ca-2.pdf Notice of Occupational Disease and Claim for Compensation
ca-2a.pdf Notice of Recurrence
ca-5.pdf Claim for Compensation by Widow, Widower, and/or Children
ca-5b.pdf Claim for Compensation by Parents, Brothers, Sisters, Grand Parents, or Grand Children
ca-6.pdf Official Supervisor's Report of Employee's Death
ca-7.pdf Claim for Compensation
ca-7a.pdf Time Analysis Form, used for claiming compensation, including repurchase of paid leave
ca-7b.pdf Leave Buy Back (LBB) Worksheet/Certification and Election
ca-10.pdf What a Federal Employee Should Do when Injured at Work
ca-12.pdf Claim for Continuance of Compensation under the Federal Employees' Compensation Act
CA-16.pdf The CA-16 is not available online because it guarantees payment of medical expenses. See attached for more info.
ca-17.pdf Duty Status Report
ca-20.pdf Attending Physician's Report
ca-35.pdf Evidence Required in Support of a Claim for Occupational Disease, Hearing Loss, Asbestos-Related Illness, Coronary/Vascular Condition, Skin Disease, Pulmonary Illness, Psychiatric Illness, Carpal Tunnel Syndrome
ca-40.pdf Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. 8102a
ca-41.pdf Claim for Survivor Benefits under the Federal Employees' Compensation Act Section 8102a Death Gratuity
ca-42.pdf Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity
ca-278.pdf Claim for Reimbursement of Benefit Payments and Claims Expense under the War Hazards Compensation Act
ca-721.pdf Notice of Law Enforcement Officer's Injury or Occupational Disease
ca-722.pdf Notice of Law Enforcement Officer's Death
ca-1031.pdf Letter to Dependents to Verify Claimant Support
ca-1074.pdf Letter to Parents in Death Claim Development
ca-1108.pdf Statement of Recovery Letter with Long Form
ca-1122.pdf Statement of Recovery Letter with Short Form
ca-2231.pdf Claim for Reimbursement Assisted Reemployment
cm-908.pdf Notice of Termination,Suspension,Reduction, or Increase in Benefit Payments
ee-1.pdf Worker's Claim for Benefits under the Energy Employees Occupational Illness Compensation Program Act
ee-2.pdf Survivor's Claim for Benefits under the Energy Employees Occupational Illness Compensation Program Act
ee-3.pdf Employment History for a Claim under the Energy Employees Occupational Illness Compensation Program Act
ee-4.pdf Employment History Affidavit for a Claim under the Energy Employees Occupational Illness Compensation Program Act
ee-7.pdf Medical Requirements under the Energy Employees Occupational Illness Compensation Program Act
owcp-1.pdf Agreement and Undertaking
owcp-04.pdf Uniform Billing Form
owcp-5a.pdf Work Capacity Evaluation Psychiatric/Psychological Conditions
owcp-5b.pdf Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
owcp-5c.pdf Work Capacity Evaluation for Musculoskeletal Conditions
owcp-16.pdf Rehabilitation Plan and Award
owcp-17.pdf Rehabilitation Maintenance Certificate
owcp-20.pdf Overpayment Recovery Questionnaire
owcp-44.pdf Rehabilitation Action Report
owcp-915.pdf Claim for Medical Reimbursement
owcp-957.pdf Medical Travel Refund Request
owcp-1168.pdf Provider Enrollment Form
owcp-1500.pdf Health Insurance Claim Form
SF-1199A-2012.pdf SF1199A Direct Deposit Sign-Up Form
cm-929.pdf Report of Changes That May Affect Your Black Lung Benefits
cm-981.pdf Certification by School Official
cm623.pdf Representative Payee Report
cm623s.pdf Representative Payee Report
cm-787.pdf Physician's/Medical Officer's Statement
cm893.pdf Certificate of Medical Necessity
cm-910.pdf Request To Be Selected As Payee
cm-911.pdf Miner's Claim For Benefits Under The Black Lung Benefits Act
cm-911a.pdf Employment History
cm-912.pdf Survivor's Form For Benefits Under The Black Lung Benefits Act
cm-913.pdf Description Of Coal Mine Work and Other Employment
cm-921.pdf Instructions For Completion of Form CM-921
cm929p.pdf Report of Changes That May Affect Your Black Lung Benefits
cm933.pdf Roentgenographic Interpretation
cm933b.pdf Roentgenographic Quality Reading
cm972.pdf Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor
cm988.pdf Medical History and Examination for Coal Mine Workers' Pneumoconiosis
cm1159.pdf Report of Arterial Blood Gas Study
cm2907.pdf Report of Ventilatory Study
cm2970.pdf Operator Response to Schedule for Submission of Additional Evidence
cm2970a.pdf Operator Response to Notice of Claim