Notice of Recurrence

OMB 1240-0009

This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.

The latest form for Notice of Recurrence expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CA-2a Notice of Recurrence Form and Instruction
National Average Weekly Wage for non-supervisory workers on private non-agriculture pay rolls as computed by BLS as of Aug 2023.pdf Supplementary Document
60 day FRN 8.7.23.pdf Supplementary Document
Privacy Act System of Records - FEC.docx Supplementary Document
Section 8149 for CA-2a 2023.docx Supplementary Document
dol govt - 1.pdf Supplementary Document
20 CFR 10.104 Supplemental Documentation.pdf Supplementary Document
OPM Salary Table 2023. RUS.pdf Supplementary Document
1240-0009 Supporting Statement_2023_MN_Clean version.docx Supporting Statement A
Notice of Recurrence Form and Instruction

All Historical Document Collections

202310-1240-002 Approved without change	Revision of a currently approved collection	2023-12-06
202005-1240-006	Extension without change of a currently approved collection	2020-10-30
201703-1240-006 Approved without change	Revision of a currently approved collection	2017-08-31
201401-1240-001 Approved without change	Revision of a currently approved collection	2014-06-25
201101-1240-001 Approved without change	Revision of a currently approved collection	2011-05-02
201003-1240-009 Approved without change	Extension without change of a currently approved collection	2010-03-12