Printing - FECA-PT2 - National Association of Letter Carriers

2-0806 Exhibit 6: Sample Letter to Claimant--Carpal Tunnel Syndrome
Dear CLAIMANT NAME:
I am writing in reference to your claim for benefits under the Federal Employees' Compensation Act
(FECA) for carpal tunnel syndrome. 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. Describe in detail the work-related activities which you believe contributed to your condition.
Specifically describe all duties which required exertion or repeated motion of the wrist(s) or hand(s).
2. How often did you perform the activities described? How long did you perform the activity before
taking a break or doing something else?
3. Describe all activities outside your Federal employment, i.e., in other work, at home, or with any
hobbies, which involve repetitive hand or wrist movement. Do you play tennis, racquetball, or a musical
instrument?
4. Describe the development of your condition. When did you first notice it? Has it come and gone or
has it been present continuously? What symptoms have you experienced? What seems to make it
worse? Better? What treatment has been effective in controlling or curing it?
5. Describe all previous injuries to the hand, arm, or wrist. Have you ever been diagnosed as having
gout, arthritis, hypothyroidism, or diabetes? If so, provide details.
6. Provide a detailed medical report from your treating physician which describes your symptoms;
results of examinations and tests (including Phalen's and Tinel's signs and results of any nerve conduction
or EMG studies); 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 work activities
in your Federal employment contributed to your condition, an explanation of how such exposure
contributed should be provided.
7. Provide the name, address and phone number of your attending physician(s).
8. Sign and return a medical release form for each physician or medical facility who has treated you
for the claimed condition. Two forms are enclosed for this purpose. This will allow us to correspond
directly with your physician(s) if additional information or clarification is necessary.
FECA-PT2 Printed: 06/08/2010 248