Form CA-2a Notice of Recurrence

Notice of Recurrence

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U.S. Department of Labor

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Office of Workers' Compensation Programs

Employee: Complete Part A below if you experienced a recurrence as defined by OWCP on page 4 of this form. OMB No. 1240-0009
Employing Agency (Supervisor or Compensation Specialist): Complete Part B.
Expires: 01/31/2024
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.
Part A - Employee
2. Social Security Number 3. OWCP file number for
original injury

1. Name of employee (Last, First, Middle Initial)
4. Date of Birth

Mo./Day/Yr.

6. Home telephone

5. Sex
Male

Female

7. Home mailing address (include street address, city, state, and ZIP code).
See instructions for address requirement.

8. Dependents
Spouse
Child/Children under 18 years

City

State

9. Name and Address of Employing Agency
at time of original injury (number, street, city, state, ZIP code)

11. Date and Hour
of original injury
(Mo./Day/Yr.)

12. Date and Hour
of recurrence
(Mo./Day/Yr.)

16. Are you claiming?
Check both if applicable.
Medical Treatment

Other, e.g., qualifying student under age 23

Zip Code

10. 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.

13. Date and Hour stopped
work after recurrence
(Mo./Day/Yr.)

14. Date and Hour pay stopped 15. Date and Hour
returned to work
after recurrence
(Mo./Day/Yr.)
(Mo./Day/Yr.)

17. Date of first medical treatment 18. Name and address of treating physician
following recurrence
(Mo./Day/Yr.)

Time Loss From Work
19. After returning to work following the original injury, were you in any way limited in performing your usual duties?
(If so, explain. Also state how long these limitations continued.)

Yes

No

20. Describe your condition since you returned to work, including the nature and frequency of all medical treatment received.

21. Describe how and when the recurrence happened. Explain why you believe your current condition is related to the original injury.

22. 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.

I hereby claim medical treatment if needed and up to 45 days Continuation of Pay if disabled from work.
I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement,
misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that
person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or
imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits. I understand that by
signing this form, I authorize any physician or hospital (or any other person, institution, corporation, or government agency) to furnish any desired information to the U.S.
Department of Labor, Office of Workers’ Compensation Programs (or to its official representative).This authorization also permits any official representative of the Office to
examine and to copy any records concerning me.

23. Signature of employee

24. Date (Mo./Day/Yr.)

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or
modifications, please contact OWCP. See form instructions for REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.

CA-2a (Rev. 11-17)

Part B - Federal Employing Agency
25. Name and address of reporting office (include street address, city, state and ZIP Code)

City

OWCP Agency Code

State

OSHA Site Code

Zip

27. Date of first return to
FULL-TIME REGULAR duty
following original injury

26. Employee's duty station (include street address, city, state, and ZIP Code)

City
28. Regular work hours
From:

State

33. Date pay
stopped after
recurrence

Mo./Day/Yr.

29. Regular work days
To:

30. Date of injury

Zip

Sun.

Mo./Day/Yr.

31. Date of
recurrence

Mo./Day/Yr.

34. Dates COP
paid for
recurrence

Mon.

Mo./Day/Yr.
Mo./Day/Yr.
From:

Tues.

Wed.

32. Date stopped
work after
recurrence
35. Date returned
to work after
recurrence

Thurs.

Mo./Day/Yr.

Mo./Day/Yr.

Fri.

Sat.

Time:

Time:

To:
36. Did the employee receive medical care at an agency facility due to 37. At the time of the injury did your agency authorize medical
the recurrence?
treatment on Form CA-16?
Yes
Yes
If so, please attach all relevant medical records.
No
No
38. After the original injury, did you make any accommodations or adjustments in the employee's regular duties due to injury-related limitation?
Yes

No

If so, provide full details.

39. After return to work, did the employee sustain any other injury or illness which affected performance of his or her duties? If so, provide full
details.

40. Please review the statements made by the employee in Part A of this form and provide any relevant comments and additional information.

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.
41. Signature of Supervisor or Compensation Specialist 42. Title
43. Work phone
44. Date (Mo./Day/Yr.)
(at time of recurrence)

CA-2a (Rev. 11-17)

Part C - Employee
(To be completed by the employee if not employed with the Federal Government at the time of the claimed recurrence)
1. 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.

2. 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.

3. Describe all educational and/or vocational training received since your original injury. Include any licenses or certificates earned.

4. What was your rate of pay if you stopped work due to this recurrence?
$

per

5. Do you claim compensation for lost wages?
If so, for what period?

Yes

No

through

6. Have you received any pay during the period claimed?

Yes

No

If so, how much and from what source?

7. Signature of Employee

8. Date (Mo./Day/Yr.)

CA-2a (Rev. 11-17)

INSTRUCTIONS FOR COMPLETING FORM CA-2a NOTICE OF RECURRENCE
DEFINITION OF RECURRENCE
A Recurrence of the Medical Condition is the documented need for additional medical treatment after release from treatment for the workrelated injury or condition. Continuing treatment for the original condition is not considered a recurrence.
A Recurrence of Disability is a work stoppage caused by:
• A spontaneous return of the symptoms of a previous injury or occupational disease without intervening cause;
• A return or increase of disability due to a consequential injury (defined as one which occurs due to weakness or impairment caused by
a work-related injury); or
• Withdrawal of a specific light duty assignment when the employee cannot perform the full duties of the regular position. This
withdrawal must have occurred for reasons other than misconduct or non-performance of job duties. See 20 C.F.R. 10.5 (x).
IF A NEW INJURY OR CONDITION DUE TO OCCUPATIONAL EXPOSURE OCCURS, AND DISABILITY OR THE NEED FOR MEDICAL
CARE RESULTS, A NEW FORM CA-1 OR CA-2 SHOULD BE FILED. This is true even if the new incident involves the same part of the body
as previously affected.
INSTRUCTIONS FOR EMPLOYEE
• Review the definition of "recurrence" given above. If you believe that you have sustained a recurrence, complete Part A of this form. Attach
a separate sheet of paper if needed to provide full details. Please ensure you provide your current address at the time of your claimed
recurrence. The address is to include: the House Number and Street Name, City/Town, State, and Zip Code.

•
•
•

•

For the FECA program to effectuate proper claims management, a FECA claimant should provide the home address where he or she
resides.
If you worked for the Federal Government at the time of the recurrence, submit Form CA-2a to your employing agency. If you no
longer work for the Federal Government, complete Parts A and C of this form and submit all materials directly to the Office of
Workers' Compensation Programs (OWCP).
If you are claiming a recurrence of disability for an occupational illness, or if all 45 days of continuation of pay (COP) have been
used, you may claim wage loss on Form CA-7. The OWCP will pay compensation if the claim is approved.
Arrange for your attending physician to submit a detailed medical report. The report should include: dates of examination and
treatment; history as given by you; findings; results of x-ray and laboratory tests; diagnosis; course of treatment; and the treatment
plan. The physician must also provide an opinion, with medical reasons, regarding causal relationship between your
condition and the original Injury. Finally, the physician should describe your ability to perform your regular duties. If you are
disabled for your regular work, the physician should identify the dates of disability and provide work tolerance limitations.
If other physicians treated you after you returned to work following the original injury, obtain similar medical reports from each of them.
INSTRUCTIONS FOR EMPLOYING AGENCY

• After the employee has completed Part A, promptly complete Part B and submit the form to OWCP, unless: the claimant is still receiving
continuation of pay (COP); the recurrence is for medical care only and the claim is still open; or the claimant is currently requesting neither
wage-loss compensation nor payment of medical expenses. In these instances, file the form in the Employee Medical Folder.
• If COP is being paid, obtain medical evidence using Form CA-17, "Duty Status Report", as often as circumstances indicate.
• For recurrences of disability which continue after the 45 days of COP have expired or which involve occupational illness, instruct
the employee to file Form CA-7.
Privacy Act
The Privacy Act of 1974 as amended, (5 U.S.C. 552a), and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C
8101, et. seq) authorizes collection of this information. The information will be used to determine continuing entitlement to benefits. Furnishing
the requested information is required for a claimant to obtain or retain a benefit. Failure to provide the information may result in the delay of a
claim or payment of benefits, or may result in an unfavorable in a delay of a claim or payment of benefits, or result in an unfavorable decision or
reduced levels of benefits. Additional disclosures of this information may be to: (1) to determine eligibility for and the amount of benefits payable
under the FECA, and may be verified through computer matches or other appropriate means; (2) 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; (3) to other Federal agencies, other government entities, and to privatesector agencies and/or employers as part of rehabilitative and other return-to-work programs and services; (4) 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; and (5) 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.
Public Burden Statement
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting
burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any
comments regarding this estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send
them to the Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C.
20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

CA-2a (Rev. 11-17)

Requests for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP, DFEC, in the form of communication assistance,
accommodation(s) and/or modification(s) to aid you in the FECA claims process. For example, we will provide you with copies of documents in
alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to accommodate your
disability. please contact your OWCP claims examiner to ask about this assistance.

CA-2a (Rev. 11-17)