Printing - FECA-PT2 - National Association of Letter Carriers

I am writing in reference to your claim for benefits under the Federal Employees' Compensation Act
(FECA) for a pulmonary condition. 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 exposure or contact which you believe contributed to your
illness.
a. To what were you exposed, e.g., smoke, fumes, dust? How did you realize you were
exposed? Could you detect the substance on work surfaces, in the air?
b. Describe your exposure. How often were you exposed? Approximately how many hours
per day and days per week? Did it vary over time? If so, how?
c. Did you use protective equipment such as a respirator or a mask? What tasks did you
perform which required the claimed exposure or contact? Were you aware of any precautions to
take, or hazards of use identified by the manufacturer or your employer?
2. Describe all exposure to pulmonary irritants outside of your Federal employment, i.e. in other
employment, at home, or with any hobbies.
3. Describe the development of the claimed 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?
4. Describe all previous pulmonary conditions and all known allergies. Have you ever had asthma or
bronchitis before? Provide all relevant details.
5. 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?
6. Provide a comprehensive medical report from your treating physician which describes your
symptoms; results of examinations and tests; 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.
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 enable this Office to
correspond directly with your physician(s) if additional information or clarification is necessary.
FECA-PT2 Printed: 06/08/2010 265