Summary of Revisions

Summary of Revisions

OMB 1240-009, CA-2a, Claim for Recurrence (4-21-2011)

Page 1

Underneath DOL Seal

• Delete the current expiration date, and place with, XX-XX-XXXX.

• Bottom of page--Delete the word Form and change Form/Revision Date as follows:

CA-2a (Rev. 12-10)

• Add the number “16, Recurrence due to”, in the Medical Treatment Only/Time Loss from work area.

Page 2

• Bottom of page--Revise as follows:

CA-2a

Page 2 (12-10)

Page 3

• Remove Privacy Act statement and place with revisions as noted below on page 4

• Revised bottom of page as follows:

CA-2a

Page 3 (12-10)

Page 4

• After Instructions for Employing Agency, Add and center the word Privacy Act as a caption, and add the following Privacy Act Statement.

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are here by

notified that: (1) The Federal Employees' Compensation Act, as amended and extended

(5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation

Programs of the U. S .Department of Labor, which receives and maintains personal

information on claimants and their immediate families. (2) Information which the Office

has will be used to determine eligibility for and the amount of benefits payable under the

FECA, and may be verified through computer matches or other appropriate means. (3)

Information may be given to the Federal agency which employed the claimant at the time

of injury in order to verify statements made, answer questions concerning the status of

the claim, verify billing, and to consider issues relating to retention, rehire, or other

relevant matters. (4) Information may also be given to other Federal agencies, other

government entities, and to private-sector agencies and/or employers as part of

rehabilitative and other return-to-work programs and services. (5) Information may be

disclosed to physicians and other healthcare providers for use in providing treatment or

medical/vocational rehabilitation, making evaluations for the Office, and for other

purposes related to the medical management of the claim. (6) Information may be given

to Federal, state and local agencies for law enforcement purposes, to obtain information

relevant to a decision under the FECA, to determine whether benefits are being paid

properly, including whether prohibited dual payments are being made, and, where

appropriate, to pursue salary/administrative offset and debt collection actions required or

permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's

social security number (SSN) or tax identifying number (TIN) on this form is mandatory.

The SSN and/or TIN, and other information maintained by the Office, may be used for

identification, to support debt collection efforts carried on by the Federal government,

and for other purposes required or authorized by law. (8) Failure to disclose all requested

information may delay the processing of the claim or the payment of benefits, or may

result in an unfavorable decision or reduced level of benefits.

Note: This notice applies to all forms requesting information that you might receive

from the Office in connection with the processing and adjudication of the claim you

filed under the FECA.

• Add Form/Revision Date/Page #'s as follows:

CA-2a

Page 4 (12-10)

Revisions coordinated with Branch Chief, Regulations and Policy & SOL

Marcus J. Sharpless

Special Examiner

4/21/2011