Printing - FECA-PT2 - United States Department of Labor

2-0402 Exhibit 1: Worksheet For Investigation Of FEC Claimant
Name of Claimant or Beneficiary:_________________________________
OWCP Case File No._______________________ SSN___________________
Address:_________________________________________________________
_________________________________________________________________
Telephone Number:______________________________
Date of Injury:________________________________
Condition(s) for Which Benefits are Claimed/Paid:________________
_________________________________________________________________
Claimant's Occupation:___________________________________________
Employment Address:______________________________________________
_________________________________________________________________
Has case been accepted? Yes___ No___ If so, is compensation being
paid? Yes___ No___ If so, at what rate? $________ each four weeks
Purpose of Investigation:
____Determine facts surrounding injury or exposure
____Periodic roll employment check
____Periodic roll activity surveillance
____Overpayment financial questionnaire
____Other (explain below)
Reasons investigation is requested:______________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Specific actions requested (interview, observation, etc.)________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Claims Examiner:_____________________________ Date:______________
Telephone Number:________________________
2-0402 Exhibit 2: Incident Report, Form DL-156 Page 1 (Link to Image)
2-0402 Exhibit 2: Incident Report, Form DL-156 Page 2 (Link to Image)
2-0402 Exhibit 3: Referral of FEC Case to the OIG Form CA-503 (Link to Image)