Printing - FECA-PT2 - National Association of Letter Carriers

2-0806 Exhibit 10: Sample Letter to Claimant--Hearing Loss
Dear CLAIMANT NAME:
I am writing in reference to your claim for benefits under the Federal Employees' Compensation Act
(FECA) for hearing loss. 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 employment 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 source(s) of noise,
number of hours of exposure per day, and use of any safety devices (such as ear defenders) to protect
against noise exposure. If used, state the approximate number of hours per day and days per week they
were used.
2. Are you still exposed to hazardous noise at work? If not, give the date you were last exposed.
3. Give the date you first noticed your hearing loss.
4. Give the date you first related your hearing loss to work exposure and explain how you realized
this.
5. Have you ever previously filed a workers' compensation claim for hearing loss or an ear condition?
If so, give date of claim, name and address of the agency where filed, benefits received, and file number.
6. Describe all previous ear or hearing problems. If you have been examined or treated by a doctor
for an ear or hearing problem, provide copies of all medical reports and audiograms.
7. Describe any hobbies which involve exposure to loud noise.
8. [FREE FLOW IF DESIRED]
We may write directly to a physician or any other party who may be able to provide information which will
help us decide your eligibility for benefits. Our efforts are intended to assist you in collecting evidence.
Please understand that it is ultimately your responsibility, as the claimant, to provide or ensure the
provision of all evidence needed to decide your claim. Whenever we request information, we will send you
a copy so you may ensure that the requested information is provided as soon as possible.
We are committed to making a timely decision on your claim. We will allow 30 days for the submission of
all requested evidence. If we have not received the requested information, an indication that it is
forthcoming, or evidence that the information is not necessary to decide your claim, we will render a
decision on your claim based on the evidence in file.
FECA-PT2 Printed: 06/08/2010 254