Figure SC810.F10. Instructions for completing Form CA-2
CPMS INSTRUCTIONS FOR COMPLETING FORM CA-2,
NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR
The employee or the employee's representative fills out Items 1 through 18 as
Item 1. Employee's last name, first name, middle name (enter NMN if no middle
Item 2. Employee's social security number.
Item 3. Employee's date of birth (month, day, year) - NOT TODAY'S DATE OR
Item 4. Employee's gender.
Item 5. Employee's home telephone number with area code; if no home phone
Item 6. Grade and pay as of date of last exposure.
Item 7. Employee's complete home mailing address, including ZIP code.
Item 8. Employee marks the appropriate boxes - numbers are not required. If no
dependents, enter "NONE."
Item 9. Employee's job title, employees pay plan, and the four numbers of the
occupational series as listed on the SF 50.
Item 10. Work location where disease or illness developed. Show complete
address including 9-digit ZIP code if location is not the same as Item 8.
Item 11. The date that the employee first became aware of the disease or
illness. (This may or may not be the same date that he or she realized that it was
caused or aggravated by his or her employment.)
Item 12. The date that employee realized the disease or illness was caused or
aggravated by employment.
Item 13. The employee should be very specific.
Item 14. Description of the condition claimed to be work-related.
Item 15. If an entry is required, give a specific reason.
Item 16. If separate narrative on the disease is not submitted with this form,
explain reason for delay.
DoD 1400.25-M, December 1996
CHANGE 6 (6/29/00)
SC810, APP 2, FIGURE 10
Item 17. If required medical forms are not attached, explain reason for delay.
Item 18. Be sure the normal signature is used. This is the actual date the
completed Form CA-2 is submitted to the supervisor.