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 skin 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 skin
condition.
a. Were you exposed to a chemical substance such as paint, dyes, fumes, solvents, etc.?
Provide the trade name, generic name, ingredients and manufacturer if known.
b. During the performance of your work, were you exposed to intense sunlight, extremes of
temperature, or other unusual physical factors?
c. Describe your exposure. How often were you exposed and for approximately how many
hours per day and days per week? Did it vary over time? If so, how?
d. What tasks did you perform which required the claimed exposure or contact? Were you
aware of any precautions to take? If so, did you use protective measures such as glove, mask,
etc.? Were the hazards of use identified by the manufacturer or your employer?
2. Describe exposures to chemicals and physical factors such as prolonged sunlight, outside your
Federal employment (other job, hobbies, recreation, etc.)
3. Describe the development of the claimed condition. When did you first notice it? Has it been a
continuous problem or does it come and go? What specific symptoms have you experienced? What
seems to make it worse? Better? What treatment has been effective in controlling or curing it?
4. Describe any previous skin conditions and any known allergies.
5. 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.
6. Provide the name, address and phone number of your attending physician(s).
7. 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 us to correspond
directly with your physician(s) if additional information or clarification is necessary.
8. [FREE FLOW IF DESIRED]
FECA-PT2 Printed: 06/08/2010 268