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2-0806 Exhibit 1: Sample Development Letter Dear NAME OF PHYSICIAN: I am writing in reference to the claim for benefits under the Federal Employees' Compensation Act (FECA) filed by CLAIMANT NAME for CLAIMED CONDITION, which is claimed to be related to factors of Federal employment. We note that you have treated this claimant for the claimed condition. For the Office of Workers' Compensation Programs (OWCP) to determine whether benefits under the FECA are payable, your findings and opinion are needed. Please provide us with a detailed, narrative medical report which fully responds to all of the questions on the attached list, and which provides medical reasons for all opinions stated. Also enclosed is a Statement of Accepted Facts which outlines all of the relevant facts which OWCP accepts as accurate in this case. Please use this document as your frame of reference in preparing your response. Your fee for providing a report which fully answers the questions posed will be paid by the OWCP. Please complete the enclosed Form OWCP-1500, attach it to your original report, and submit both directly to OWCP at the address on the letterhead to ensure prompt payment. Please also send a copy of the report to your patient, CLAIMANT NAME. Thank you for your assistance. Your full reply within 30 days will be very much appreciated. If you have any questions regarding this request, please call me on TELEPHONE NUMBER. Sincerely, CLAIMS EXAMINER NOTICE TO CLAIMANT: Please be advised that this letter is intended to help you obtain medical evidence needed to decide your claim. However, you are responsible for ensuring that all requested information is provided as soon as possible. We are committed to making a timely decision on your claim. If we have not received the requested information, a statement that it is forthcoming, or evidence that shows that the information requested is not necessary to decide your claim, we will be required to make a decision on your claim based on the evidence in file. FECA-PT2 Printed: 06/08/2010 236
2-080 Exhibit 2: Sample Letter to Claimant--Asbestosis Dear CLAIMANT NAME: I am writing in reference to your claim for benefits under the Federal Employees' Compensation Act (FECA) for an asbestos-related illness. We have received and reviewed [DESCRIBE WHAT WAS RECEIVED]. This information is not sufficient for us to determine whether you are eligible for benefits because [EXPLAIN WHY EVIDENCE INSUFFICIENT]. Please provide the information requested below to us at the address on the letterhead. Include as much detail as possible. Send a copy of your response to your employer for comments. 1. List your work history by employer, job title, and inclusive dates. Include all employment (Federal and non-Federal) as well as military service. For each job title, describe the work you performed, the type of asbestos material used, locations where exposure occurred, period of exposure, number of hours per day and days per week exposed, and the type and frequency of safety precautions used (mask, respirator, protective clothing, ventilation, etc.) 2. Describe any exposure you have had to other toxic substances affecting the lung. If none are known, so state. 3. Describe all previous pulmonary conditions and allergies, particularly those of a respiratory nature. Have you ever had asthma or bronchitis? Provide all relevant details. 4. Do you smoke cigarettes, cigars or a pipe? How much and for how long have you smoked? If you don't smoke now, have you ever? How much, for how long, and when did you quit? 5. Provide a detailed medical report from your treating physician which describes your symptoms; results of examinations and tests (including chest x-ray report); diagnosis; the treatment provided; the effect of treatment; and the doctor's opinion, with medical reasons, on the cause of your condition. Specifically, if your doctor feels that exposure in your Federal employment contributed to your condition, an explanation of how such exposure contributed should be provided. 5. We have received a medical report from your physician. However, it is not sufficient to support your claim because [EXPLAIN WHY REPORT INSUFFICIENT]. Please provide an additional report which specifically discusses the following: [EXPLAIN WHAT NEW REPORT SHOULD INCLUDE]. 6. Give the date you first became aware of your lung condition. FECA-PT2 Printed: 06/08/2010 237 OR 7. Give the date you first related your lung condition to work exposure and explain how you realized this. 8. Have you ever previously filed a workers' compensation claim for a lung condition? If so, give date of claim, name and address where filed, benefits received, and file number.
Page 1 and 2:
LIST OF CHAPTERS PART 2 - CLAIMS (I
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which may be useful to the CE. b. C
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d. Continuation of Pay. An employee
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o. Review of OWCP Decisions. Under
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2-0300 COMMUNICATIONS TABLE OF CONT
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2-0300-4 Regular Correspondence 4.R
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(b) Formal Decision. If a formal de
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If the information requested cannot
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eferred to the NOO for adjudication
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2-0400-6 Requesting Files 6. Reques
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the file. This process should mainl
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2-0400-10 Case Transfers and Loans
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2-0401 AUTOMATED SYSTEM SUPPORT FOR
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names and addresses is optional. By
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PW: Entitled to payment on periodic
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AM/C1: Condition accepted. Up to $1
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full appeal rights, and the adjudic
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B Both A Aggravation 2-0402 SECURIT
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a. Signatures. The CE must review c
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(a) The particular issues about whi
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c. Review by DD. Upon receipt of th
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disposition, a report, enclosing th
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2-0500 CONFERENCING TABLE OF CONTEN
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necessary to identify the official(
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2-0500-6 Senior CE Actions 6. Senio
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2-0500-9 Due Process 9. Due Process
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This chapter outlines the major ste
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(d) Been notified that OWCP will pr
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2-0600-4 Initial Actions 4. Initial
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2-0600-5 Nurse Services 5. Nurse Se
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assess the claimant's environment a
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(4) Timely responses to telephone c
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for guidance in composing such ques
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(4) Only if the CE has taken these
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(1) RS Actions. If the claimant agr
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(3) Absent such a recovery, the OWC
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(c) After any training or other pre
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under way and the CE determines tha
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2-0600 Exhibit 1: Sample Letter to
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2-0600 Exhibit 3: Example of Letter
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2-0600 Exhibit 5: Planning Chart fo
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period, and each new recurrence. a.
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a. QCM Screen. When the QCM screen
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(c) Confirmation of Data. After ent
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(1) NFN*--Referred to Field Nurse.
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2-0601-6 Effect of RTW on QCM Statu
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2-0601 Exhibit 1: Disability Tracki
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SRE Referred to SrCE for Conference
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21. FECA Death Gratuity 4/10 10-06
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. Claimant. The claimant is respons
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2-0700-6 Adjudication 6. Adjudicati
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(3) If the parties lived apart for
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(3) If the child does not begin pos
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Compensation was terminated effecti
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. Dependency Criteria. The test of
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(3) Proof of physical or mental inc
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The CE should prepare a memorandum
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. Employee Status. The $200 payment
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(b) Form CA-1617 should be released
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2-0700-20 Gratuity 20. Gratuity fro
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2-0700 Exhibit 1: Percentages of En
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2-0800-2 Definitions 2. Definitions
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. Employing Agency. The FECA requir
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claimant, the CE should send a copy
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(3) The case must be coded as withd
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entire group of cases must be adjud
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2-0800-10 Investigation 10. Investi
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2-0800-13 Affirmative Defense 13. A
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2-0801 TIME TABLE OF CONTENTS Parag
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5 U.S.C. 8122 on the ground that no
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(4) If a claim is not received by O
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(1) Disappearance During a Period o
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2-0802 CIVIL EMPLOYEE TABLE OF CONT
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2-0802-1 Purpose and Scope 1. Purpo
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(1) The precise time when the worke
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2-0802-8 Contract Job Cleaners Used
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2-0802-13 Volunteer Workers with th
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(1) Whether, prior to the transfer
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. The pay rate for compensation pur
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2-0802-24 U.S. Park Police and Secr
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a participant or crew leader servin
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2-0803 FACT OF INJURY TABLE OF CONT
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2-0803-4 Development of Factual Evi
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2-0804 PERFORMANCE OF DUTY TABLE OF
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time before or after the end of the
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(a) A diagram showing the boundarie
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d. Workers in a Travel Status. (1)
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2-0804-6 To and From Work 6. To and
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(a) The reason the employee was req
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(1) At the time of the injury, the
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(1) Martha G. List, 26 ECAB 200. Em
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duty, the CE may approve the case.
Page 185 and 186: action taken; and (4) Statements fr
Page 187 and 188: 2-0804-14 Statutory Exclusions 14.
Page 189 and 190: would justify such disobedience. (c
Page 191 and 192: (2) The official superior should al
Page 193 and 194: c. Development. (1) It is the CE's
Page 195 and 196: such as soliciting new members or c
Page 197 and 198: c. Performance Ratings. The Board r
Page 199 and 200: Where an employee asserts that emot
Page 201 and 202: The Board noted that Cannon was unl
Page 203 and 204: Since both cases involve procedures
Page 205 and 206: Ashberry's disability was not compe
Page 207 and 208: no longer be considered so in light
Page 209 and 210: 2-0804-18 Employing Agency Physical
Page 211 and 212: f. This matter was initially addres
Page 213 and 214: compensation would be payable for t
Page 215 and 216: limited to the period of work-relat
Page 217 and 218: (6) Certain other kinds of cases re
Page 219 and 220: (2) A nurse becomes disabled by pul
Page 221 and 222: the body originally injured is term
Page 223 and 224: 2-0806 OCCUPATIONAL ILLNESS TABLE O
Page 225 and 226: 2-0806-1 Purpose and Scope 1. Purpo
Page 227 and 228: the following steps, depending on w
Page 229 and 230: (4) Exposure to and Identification
Page 231 and 232: While records of past medical treat
Page 233 and 234: the medical connection between lift
Page 235: (b) The medical evidence presented
Page 239 and 240: 2-0806 Exhibit 3: Sample Letter to
Page 241 and 242: TITLE _____________________________
Page 245 and 246: eason, you should call or write to
Page 249 and 250: 9. [FREE FLOW IF DESIRED] We may wr
Page 255 and 256: If you do not understand any part o
Page 261 and 262: stressful situations in your person
Page 263 and 264: TITLE FECA-PT2 Printed: 06/08/2010
Page 265 and 266: I am writing in reference to your c
Page 269 and 270: We may write directly to a physicia
Page 271 and 272: 2-0806 Exhibit 20: Sample Questions
Page 273 and 274: TA Amputation TB Back strain TC Con
Page 275 and 276: (D )Other Disability, Occupational
Page 277 and 278: a. Traumatic Injury. If an air traf
Page 279 and 280: 2-0807-6 Period of Entitlement 6. P
Page 281 and 282: d. Return to Duty. The injured empl
Page 283 and 284: f. The injury was not reported on a
Page 285 and 286: W = Total number weeks worked P/W =
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COP is paid for the entire period o
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(c) When the physician's report ind
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(a) Assign or detail the employee t
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. Monitoring the Claim. (1) If Form
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(4) If conflicting information appe
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a. Permanent Total Disability (PTD)
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(1) Prior to December 7, 1940. No p
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(2) Impairment due to amputation is
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. Claims for Increased Schedule Awa
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compensation for temporary total di
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Medical. 2-0809-2 Introduction 2. I
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CE is ready to evaluate the evidenc
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the physician with a complete pictu
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(3) Personal habits such as smoking
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games or operating a construction b
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Jane Doe, date of birth 04/06/1965,
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elated to the employee’s duties;
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16. Physical Therapy 04/01 01-06 03
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evaluating the merits of medical re
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situation where ten days earlier th
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each opinion. The value of the evid
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manipulation of the body. They incl
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. The DMA's performance of these fu
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evidence from physicians who have n
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e. In cases involving a preexisting
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(1) The consultant should be asked
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value). Based on the results of thi
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However, if the impartial specialis
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2-0810-13 Exclusion of Medical Evid
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Leanna Garlington, 37 ECAB 849). Re
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(d) A suggested supplier, if any. (
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need for further treatment as detai
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2-0810-18 Transfer of Medical Care
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2-0810 Exhibit 1: Information from
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Dear CLAIMANT NAME: We need the fol
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2-0810 Exhibit 3: General Guideline
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2-0810 Exhibit 5: Sample Paragraph
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2-0810 Exhibit 7: Letter of Warning
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In addition, a primary goal of case
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(3) Release Form CA-1008 and Pamphl
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a. Where disability is present, the
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f. If the evidence obtained as a re
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eligible for disability benefits. A
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f. Physician's estimate of the date
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2-0812 PERIODIC REVIEW OF DISABILIT
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2-0812-1 Purpose and Scope 1. Purpo
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determine the status of dependents
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whether disability is related to th
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earnings or activity is in question
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eferred to the Office of Inspector
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. Suspension of Compensation. OWCP
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certification clauses on the CA-103
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SI Payment/Entitlement Suspension i
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with the return to work effort. CFF
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should be placed in a PN status. OP
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force. 10. If the business has had
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I am writing in follow up to the Fo
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2-0812 Exhibit 6 - Periodic Entitle
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Service. On 03/14/2003, the claiman
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Authorized Medical Care for Substan
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a. OPM's regulations on retention r
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d. To identify cases for early inte
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2-0813-7 Communication Among the CE
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d. Cooperative Agreement. The title
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ehabilitation process. 2-0813-11 Fa
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(2) To reduce compensation in this
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The specificity of the reasons offe
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in conjunction with graded conditio
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(1) Where the claimant cannot perfo
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2-0813 Exhibit 2: Non-Cooperation W
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2-0813 Exhibit 4: Sample Letter to
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2-0814 REEMPLOYMENT: DETERMINING WA
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Exhibits 1. Sample Letter to Claima
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. Preliminary Assessment of Positio
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(b) If the attending physician cont
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(3) The employing agency will be as
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e. Payment/Reimbursement of Relocat
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have no appeal rights attached. c.
Page 443 and 444:
were not reported to OWCP or were o
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(3) If the employee can work only p
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this instance the CE will need to e
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d. Unacceptable Reasons for Abandon
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closure of an installation, cessati
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Code, and returns to duty under ret
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If you receive an increase in pay o
Page 457 and 458:
2-0814 Exhibit 3: Sample Letter To
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RATE DATE FOR SCHEDULE AWARDS 01/10
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(1) Kinds of Appointments. The Post
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year, in the teaching profession, w
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(b) Census enumerators; (c) Casual
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The CE should consider these factor
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The greatest of these pay rates wil
Page 471 and 472:
the Department of Veterans Affairs
Page 473 and 474:
degree of expense, hardship, and in
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(2) Basic bi-weekly pay x premium p
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2-0900-9 Computing Daily Pay Rate 9
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2-0900-11 Computing Monthly Pay Rat
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The salary for these employees may
Page 483 and 484:
2-0901 COMPUTING COMPENSATION TABLE
Page 485 and 486:
2-0901-2 Related Topics 2. Related
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(4) A GS-12 CE or designated CE may
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2-0901-4 Factors in Computing Compe
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(3) For schedule award payments, th
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(4) Compensation payable for less t
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2-0901-9 Special Determinations 9.
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2-0901-11 Maximum Compensation 11.
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payment. a. Beginning Date. Schedul
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(3) ( ) (a) is capable of earning (
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automatic pay increases. For exampl
Page 505 and 506:
claimant to a higher pay rate under
Page 507 and 508:
(a) the beneficiary's maintenance,
Page 509 and 510:
Letter CA-1208 to the claimant, wit
Page 511 and 512:
01/01/76 4.4 10/10/76 18.96-28.44 9
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01/02/2000 44.98-67.47 224.91-337.3
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10/07/79 144.56 722.78 - (2,891.12)
Page 517 and 518:
*Calendar Days 01/01/2001 3.3 365 1
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PERCENTAGE TABLE OF SCHEDULE AWARDS
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2-0901 Exhibit 6: Activity Codes AC
Page 523 and 524:
12. Tennessee Valley Authority 02/9
Page 525 and 526:
. Death Benefits. When compensation
Page 527 and 528:
(3) Certification. The CE should ha
Page 529 and 530:
elected, refer the case to the inac
Page 531 and 532:
(b) If there is accrued compensatio
Page 533 and 534:
Centers, and DVA Hospitals. If the
Page 535 and 536:
(b) The claimant may be entitled to
Page 537 and 538:
d. Obtaining Elections--Educational
Page 539 and 540:
(3) The CE must advise the claimant
Page 541 and 542:
c. Injuries On and After September
Page 543 and 544:
Based on information contained in t
Page 545 and 546:
2-1000-16 Benefits for Judicial Off
Page 547 and 548:
(a) Calculate the number of weeks w
Page 549 and 550:
I. Claimants must elect between Fed
Page 551 and 552:
2-1000 Exhibit 2: OPM Contact List
Page 553 and 554:
When a third party is or may be leg
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(6) Ltr. CA-1109, Authorization to
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7. Administration of Third Party Ca
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(3) If not accurate or complete, th
Page 561 and 562:
the DCE, is urgent should be sent i
Page 563 and 564:
(3) Provide the claimant or attorne
Page 565 and 566:
for a course of action. All formal
Page 567 and 568:
In any other case, where a judgment
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(b) 5 percent of the total to be al
Page 571 and 572:
To determine the amount to be liste
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(6) Section 8133(a) of the FECA pro
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(2) The initial demand letter in an
Page 577 and 578:
of the employee. The USPS cannot re
Page 579 and 580:
not be referred to the FEEWC until
Page 581 and 582:
FECA-PT2 Printed: 06/08/2010 581
Page 583 and 584:
a. Under 5 U.S.C. § 8127(b) and in
Page 585 and 586:
. Should an application be submitte
Page 587 and 588:
and the requested fee is reduced du
Page 589 and 590:
2-1200 Exhibit 1: Sample Formal Dec
Page 591 and 592:
2-1300 LUMP SUM PAYMENTS TABLE OF C
Page 593 and 594:
2-1300-3 Requests for Lump-Sum Paym
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2-1300-4 Calculating Lump-Sum Sched
Page 597 and 598:
2-1300 Exhibit 2: Sample Appealable
Page 599 and 600:
3. REVIEW BY THE EMPLOYEES' COMPENS
Page 601 and 602:
SIGNATURE _________________________
Page 603 and 604:
We have received your request for a
Page 605 and 606:
2-1400 DISALLOWANCES TABLE OF CONTE
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2-1400-1 Purpose and Scope Purpose
Page 609 and 610:
a. Initial Disallowances. Such disa
Page 611 and 612:
(1) Failure to Appear for Medical A
Page 613 and 614:
(1) The name and location of the em
Page 615 and 616:
injury caused no disability for wor
Page 617 and 618:
(3) A specific service which the cl
Page 619 and 620:
2-1400-7 How to Issue Pre-Terminati
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(a) The case is being referred beca
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(a) Compensation is being terminate
Page 625 and 626:
. Source of Advice. District office
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usual rate, i.e., 75 percent of the
Page 629 and 630:
objective findings to support your
Page 631 and 632:
2-1400 Exhibit 3: Sample Notice of
Page 633 and 634:
2-1400 Exhibit 4: Sample Letter Con
Page 635 and 636:
2-1400 Exhibit 6: Sample Notice of
Page 637 and 638:
2-1400 Exhibit 8: Sample Letter Con
Page 639 and 640:
2-1400 Exhibit 10: Sample Letter De
Page 641 and 642:
2-1500 RECURRENCES TABLE OF CONTENT
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(d) Closure of a base or other faci
Page 645 and 646:
(1) The medical evidence needed to
Page 647 and 648:
c. Case Management. The CE should c
Page 649 and 650:
emains the same regardless of wheth
Page 651 and 652:
2-1600 REVIEW PROCESS TABLE OF CONT
Page 653 and 654:
c. Formal Decision. Chapter 2-1400
Page 655 and 656:
Page 657 and 658:
the request. H&R will acknowledge r
Page 659 and 660:
spouse or child prevents his or her
Page 661 and 662:
OWCP shall pay fees requested by wi
Page 663 and 664:
2-1601-9 Cases Returned from H&R 9.
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2-1601 Exhibit 2: Sample Letters Ac
Page 667 and 668:
Exhibit 3, page 1 of 3: Hearing Not
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Exhibit 3, page 3 of 3: Hearing Ins
Page 671 and 672:
2-1601 Exhibit 5: Request for Comme
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2-1602 RECONSIDERATIONS TABLE OF CO
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2-1602-2 Policy 2. Policy. The foll
Page 677 and 678:
d. Decision. An untimely applicatio
Page 679 and 680:
percentage of the award under the S
Page 681 and 682:
(2) The cover letter to the agency
Page 683 and 684:
2-1602 Exhibit 1: Sample Letter Ret
Page 685 and 686:
Dear CLAIMANT NAME: We have reviewe
Page 687 and 688:
2-1602 Exhibit 5: Sample Compensati
Page 689 and 690:
2-1603 APPEALS TABLE OF CONTENTS Pa
Page 691 and 692:
d. Timeliness of Filing. A person r
Page 693 and 694:
2-1603-6 Cases Returned to District
Page 695 and 696:
2-1700 SPECIAL ACT CASES TABLE OF C
Page 697 and 698:
2-1700-4 Peace Corps 4. Peace Corps
Page 699 and 700:
(2) Staff Spouses. (a) The spouses
Page 701 and 702:
Compensation for loss of wages may
Page 703 and 704:
(3) Return from Service Abroad. d.
Page 705 and 706:
Section 5 U.S.C. 8101(4), which pro
Page 707 and 708:
(1)While at a Job Corps Center, an
Page 709 and 710:
(1)Enrollees are required to report
Page 711 and 712:
coverage under 5 U.S.C. 8101. b. Co
Page 713 and 714:
Page 715 and 716:
2-1800-2 Authority 2. Authority. Ho
Page 717 and 718:
determined by the type of vehicle,
Page 719 and 720:
greatest current fair market value
Page 721 and 722:
Such certification from an architec
Page 723 and 724:
over $10,000, and that amount must
Page 725 and 726:
2-1800-7 Housing Modifications for
Page 727 and 728:
send an approval letter along with
Page 729 and 730:
By signing this agreement, all part
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By signing this agreement, all part
Page 733 and 734:
Memorandum of Agreement - Modificat
Page 735 and 736:
Memorandum of Agreement - Housing M
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