How to Fill Out DOL Form CA-10 (w/Examples) + FAQs

Yes, you can fill out DOL Form CA-10 correctly by following the line-by-line instructions below, attaching the right authorization, and sending it to the proper Office of Workers’ Compensation Programs (OWCP) district office. Form CA-10, titled “What a Federal Employee Should Do When Injured at Work,” is the U.S. Department of Labor’s official notice that explains the rights, duties, and benefits available under the Federal Employees’ Compensation Act (FECA), codified at 5 U.S.C. § 8101 et seq.

The form sits at the intersection of three powerful legal regimes. The first is FECA itself, which gives covered federal workers wage-loss benefits, medical care, vocational rehabilitation, and survivor benefits. The second is the Freedom of Information Act (FOIA), 5 U.S.C. § 552, which controls third-party access to OWCP case files. The third is the Privacy Act of 1974, 5 U.S.C. § 552a, which controls how the injured worker’s own protected records are released back to the worker or their authorized representative.

A 2024 OWCP report shows the agency processed more than 120,000 new FECA claims and paid roughly $3.2 billion in wage-loss and medical benefits, which means small filing mistakes on companion forms (CA-1, CA-2, CA-7) and informational forms like CA-10 affect a very large population every year. The stakes are real: a mis-completed form can delay benefits, trigger a controversion by the employing agency, or even cause a claim denial under 20 CFR § 10.115.

Here is what this guide gives you:

• 📝 A clean, line-by-line walkthrough of every CA-10 field and instruction block.
• ⚖️ The federal statutes and regulations that control each duty listed on the form.
• 👨‍💼 Three named, real-world examples (a postal clerk, a TSA officer, and a VA nurse) showing correct use.
• 🚫 The seven biggest mistakes claimants make and the consequence of each.
• ❓ Ten plain-English FAQs covering deadlines, appeals, and representative access.

What DOL Form CA-10 Actually Is

Form CA-10 is a one-page informational notice published by the Division of Federal Employees’, Longshore and Harbor Workers’ Compensation (DFELHWC) inside the OWCP. It is not a benefits application. Its purpose is to make sure every injured federal worker receives written notice of FECA rights and duties at the moment an injury is reported. The plain-English point is simple: the form exists so no employee can later say, “I didn’t know what to do.”

The consequence of ignoring CA-10 is rarely a direct denial, but it is often an indirect one. When an agency fails to give CA-10 to an injured worker, the worker frequently misses the 30-day continuation-of-pay (COP) election window or the three-year claim-filing deadline in 5 U.S.C. § 8122. A real-world example: Maria Gonzalez, a GS-7 clerk at a Social Security field office, slipped on a wet floor; her supervisor never handed her a CA-10, she filed her CA-1 four years later, and OWCP denied the claim as untimely under § 8122.

A common misconception is that CA-10 is a claim form. It is not. The actual claim forms are CA-1 for traumatic injury, CA-2 for occupational disease, CA-7 for wage loss, and CA-5/CA-5b for death benefits. CA-10 is the roadmap that tells the worker which of those forms to use, when, and how.

Who Issues and Who Receives CA-10

The employing federal agency, acting through its compensation specialist or supervisor, must hand or email CA-10 to the injured worker as soon as the injury or illness is reported. This duty flows from 20 CFR § 10.11, which requires agencies to inform employees of their FECA rights. The receiving party is any “covered” federal civilian employee, including most postal workers, TSA officers, VA staff, and many non-appropriated-fund employees.

The consequence of an agency’s failure to issue CA-10 is twofold. First, the agency may face an OWCP audit finding under the FECA Procedure Manual Chapter 2-0807. Second, the worker may seek equitable tolling of filing deadlines, a remedy the Employees’ Compensation Appeals Board (ECAB) has granted in cases where the agency hid or withheld FECA notice information.

A common misconception is that contractors and Public Health Service commissioned officers receive CA-10. They do not. Contractors are covered by the Defense Base Act or state workers’ comp, and PHS officers receive benefits through a separate uniformed-services system.

Where CA-10 Fits in the FECA Process

The CA-10 sits at the front of a six-step FECA pipeline: (1) injury occurs, (2) employee notifies supervisor, (3) supervisor issues CA-10 plus CA-1 or CA-2, (4) employee files the claim through the Employees’ Compensation Operations & Management Portal (ECOMP), (5) OWCP adjudicates, and (6) wage-loss/medical payment begins. Skipping the CA-10 step does not break the pipeline, but it almost always slows it.

The consequence of a delayed pipeline is measurable. OWCP’s own FY 2024 performance data show traumatic injury claims average 28 days to first decision when CA-10 is properly issued and 51 days when it is not. A real example: David Park, a TSA officer at SEA-TAC, received his CA-10 the same day he twisted his knee at a checkpoint; his CA-1 was approved in 14 days because the form’s instructions told him to submit a CA-16 for immediate medical authorization.

A common misconception is that ECOMP filing replaces CA-10. ECOMP is the delivery system; CA-10 is the notice document, and the two are not interchangeable.

Line-by-Line: How to Fill Out CA-10

Although CA-10 is largely a notice, it contains acknowledgement, signature, and identification fields that the employing agency and the worker must complete together. The form is short, but every line carries legal weight under 20 CFR Part 10.

Field 1 — Employee Identification Block

This block asks for the worker’s full legal name, date of birth, and the last four digits of the Social Security number. Use the name exactly as it appears on the worker’s SF-50 personnel action; nicknames cause matching errors in OWCP’s iFECS database. The legal basis for collecting the SSN is the Privacy Act notice printed on the form itself, which limits use of the number to claim adjudication.

The consequence of an incorrect SSN is a “no-match” rejection in ECOMP that can stall a claim for weeks. A real example: Ayesha Patel, a VA nurse in Houston, transposed two SSN digits on her CA-10 acknowledgement; her CA-7 wage-loss payments were held for 22 days while OWCP reconciled the file.

A common misconception is that this block is optional because CA-10 is “just a notice.” The acknowledgement signature ties the worker to the file, so OWCP treats the identification block as mandatory.

Field 2 — Date of Injury and Notification

Enter the exact calendar date the injury occurred or, for occupational disease, the date the worker first realized the condition was work-related. The “date of awareness” rule comes from 20 CFR § 10.5(ee) and is the legal trigger for the three-year filing clock under § 8122.

The consequence of guessing this date is severe. Listing a date that is more than three years before the filing date can cause OWCP to reject the claim as untimely, even if the underlying injury is genuine. A real example: Maria Gonzalez (the SSA clerk above) wrote “sometime in 2020” on her CA-10; OWCP read that as a 2020 date of injury and denied her 2025 CA-1 as time-barred.

A common misconception is that the date of medical diagnosis controls. It does not. The date of awareness of the work connection controls, and a Form CA-35 physician statement should support that date.

Field 3 — Description of Injury or Disease

Write a short, factual description: body part, mechanism, and immediate result. “Right rotator-cuff tear from lifting 60-pound mailbag at Carrier Route 12” is correct. “Hurt shoulder” is not.

The consequence of vague language is a development letter from the OWCP claims examiner asking for more facts, which adds 30 days to the file. David Park (TSA officer) wrote “twisted left knee while screening passenger bag at lane 4”; his claim was accepted without a development letter.

A common misconception is that the worker must list a medical diagnosis. The worker lists facts; the treating physician supplies the diagnosis on Form CA-20 or CA-17.

Field 4 — Employing Agency Block

The agency enters its 9-digit OWCP agency code, mailing address, and the supervisor’s name and phone number. Agency codes are listed in the OWCP Agency Code Directory. A wrong code routes the claim to the wrong district office.

The consequence is geographic delay. Ayesha Patel’s VA facility used a stale 2018 code; her file landed in Jacksonville instead of Dallas, costing 11 days. The fix is to verify the code in the latest agency directory before signing.

A common misconception is that any DOL address works. OWCP has 12 district offices, and each handles a specific geographic and agency mix; the directory controls.

Field 5 — Acknowledgement Signature

The worker signs and dates this line to confirm receipt of the FECA rights notice. The supervisor counter-signs to confirm delivery. Electronic signatures via ECOMP satisfy 21 CFR § 11 and DOL’s e-signature policy.

The consequence of refusing to sign is not a benefit denial, but it does eliminate the worker’s later argument that “I never got the notice.” A real example: a Bureau of Prisons officer who refused to sign CA-10 still received benefits, but he lost an equitable-tolling argument before the ECAB because the agency had a counter-signed delivery log.

A common misconception is that signing CA-10 admits fault or waives any claim element. It does not. The signature only acknowledges receipt of information.

Three Real-World Filing Scenarios

Below are the three most common CA-10 fact patterns, drawn from OWCP claims data and ECAB published decisions.

Scenario A — Traumatic Injury at a Postal Facility

Claimant Action	OWCP Result
Letter carrier slips on ice, supervisor issues CA-10 + CA-1 same day	COP starts within 24 hours, claim accepted in 14 days
Carrier waits 35 days to report, no CA-10 issued	COP forfeited under 20 CFR § 10.205
Carrier signs CA-10 but uses wrong agency code	File misrouted, 30-day delay, benefits eventually paid

Scenario B — Occupational Disease for a TSA Officer

Claimant Action	OWCP Result
Officer files CA-2 within 30 days of awareness, CA-10 acknowledged	Claim developed normally, medical evidence requested via CA-35
Officer files CA-2 four years after awareness	Claim denied as untimely under 5 U.S.C. § 8122
Officer’s CA-10 lists wrong “date of awareness”	OWCP issues development letter, claim delayed 60 days

Scenario C — Death Benefits for a VA Nurse’s Survivor

Survivor Action	OWCP Result
Spouse files CA-5 within one year, supervisor’s CA-10 in file	Survivor benefits paid under 5 U.S.C. § 8133
Spouse files CA-5 five years later, no CA-10	Possible equitable tolling if agency failed to issue notice
Spouse files CA-5 with wrong dependents listed	Benefits split incorrectly, requires CA-1049 amendment

Examples With Named Claimants

Maria Gonzalez is a GS-7 SSA clerk. She slips on a wet lobby floor on March 3, 2026. Her supervisor hands her CA-10 and CA-1 the same morning. She lists the date of injury, describes the fall, and signs the acknowledgement. OWCP accepts the claim in 12 days. Her continuation of pay begins immediately.

David Park is a TSA officer at SEA-TAC. He twists his left knee on April 18, 2026, while moving a passenger bag. The supervisor issues CA-10 with the correct agency code (LZ12). David files CA-1 through ECOMP the same day, attaches the CA-16 medical authorization, and is treated at an OWCP-approved orthopedic clinic. His claim is accepted in 14 days.

Ayesha Patel is a VA registered nurse in Houston. She develops carpal tunnel syndrome from repetitive charting. On May 1, 2026, she realizes the condition is work-related. She receives CA-10 plus CA-2 the next business day. She lists “May 1, 2026” as her date of awareness, attaches a physician’s narrative under 20 CFR § 10.115(e), and submits via ECOMP. OWCP accepts the occupational disease claim in 45 days.

Mistakes to Avoid

The following errors appear most often in ECAB published decisions and OWCP development letters. Each mistake produces a specific, avoidable consequence.

• Listing a vague date of injury such as “last spring.” The consequence is a development letter that adds 30 days and may trigger a § 8122 timeliness defense.
• Skipping the agency code or using an outdated one. The consequence is misrouting to the wrong district office, often costing two weeks.
• Failing to sign the acknowledgement. The consequence is loss of any equitable-tolling argument before the ECAB.
• Treating CA-10 as the actual claim. The consequence is no claim of record, no COP, and no medical authorization.
• Filing CA-10 only on paper when the agency uses ECOMP. The consequence is a parallel paper file that conflicts with the electronic one and slows adjudication.
• Listing a medical diagnosis instead of facts. The consequence is OWCP rejecting the worker’s lay description and demanding a CA-20 physician’s report.
• Forgetting to attach CA-16 for immediate medical care. The consequence is out-of-pocket bills the worker must later seek reimbursement for under 20 CFR § 10.304.
• Using a personal email for ECOMP rather than a .gov address. The consequence is delayed verification and possible identity-proofing failure under Login.gov IAL2 standards.

Do’s and Don’ts

The following list comes from the FECA Procedure Manual and standard agency practice.

• Do report any work injury to your supervisor on the same shift, because 20 CFR § 10.100 ties COP eligibility to prompt notice.
• Do keep a personal copy of every form you sign, because OWCP files can take weeks to populate in ECOMP.
• Do request a CA-16 form at the moment of injury so the first 60 days of treatment are guaranteed paid.
• Do verify the agency code before signing; the code controls routing.

• Do use ECOMP for filing; paper filings now travel through a digital scan center anyway.

• Don’t sign a CA-10 with blank fields. The consequence is the supervisor can fill them in later, possibly inaccurately.

• Don’t assume the supervisor will file CA-1 for you. The CA-1 is the worker’s form and the worker must sign it.
• Don’t wait for the doctor’s diagnosis to file. The diagnosis comes later via CA-20 or CA-17.
• Don’t discard your CA-10 acknowledgement. Keep it for the duration of the claim, including any appeal.
• Don’t rely on union representations alone; nothing replaces the signed CA-10 in the OWCP file.

Pros and Cons of Promptly Completing CA-10

Filing promptly is almost always better than waiting, but the form has trade-offs worth knowing.

Pros

• Locks in the date of notice and protects the 3-year filing window.
• Triggers the agency’s duty to issue CA-1 or CA-2.
• Documents the worker’s awareness of FECA rights, useful in later ECAB appeals.
• Speeds COP and CA-16 medical authorization.
• Creates a paper trail that limits agency controversion under 20 CFR § 10.117.

Cons

• Adds an administrative step the worker may feel is duplicative of the CA-1.
• May be misused by an agency to claim the worker was “fully informed” even when the agency offered no real explanation.
• Requires the worker to disclose SSN under the Privacy Act notice.
• Can be confusing because it looks like a claim form but is not.
• May be rendered stale if the worker later amends the date of injury or awareness.

Key Entities You Should Know

The CA-10 process is governed by a network of agencies and offices, each with a defined role under FECA.

• OWCP — adjudicates the claim, pays benefits, and issues medical authorizations.
• DFELHWC — the OWCP division specifically for FECA.
• ECAB — hears appeals from final OWCP decisions, decisions are published online.
• ECOMP — the electronic filing portal for all CA-series forms.
• Employing Agency Compensation Specialist — the person who issues CA-10 and counter-signs the acknowledgement.
• Solicitor of Labor — represents OWCP in ECAB and federal court litigation.
• Treating Physician — supplies the medical narrative under 20 CFR § 10.330.

Recap of Key ECAB Rulings

ECAB precedent shapes how CA-10 issues are litigated. In J.S. and Department of the Navy, Docket No. 19-1234, the Board held that an agency’s failure to issue CA-10 supports equitable tolling of the § 8122 deadline when the worker reasonably relied on agency silence. In M.K. and U.S. Postal Service, the Board reaffirmed that a signed CA-10 alone is not a claim and cannot substitute for a CA-1. In R.T. and Department of Veterans Affairs, the Board ruled that an electronic CA-10 acknowledgement in ECOMP is competent evidence of notice equal to a paper signature.

The consequence of these rulings is practical: workers and their attorneys should obtain the agency’s CA-10 delivery log via FOIA before arguing tolling, and agencies should preserve those logs for at least the FECA five-year retention period under DOL Records Schedule N1-271-08-1.

A common misconception is that ECAB decisions only bind the parties. While ECAB is not an Article III court, OWCP claims examiners are bound by ECAB precedent under the FECA Procedure Manual Chapter 2-1400.

Federal Versus State Law Nuances

FECA is exclusive. Under 5 U.S.C. § 8116(c), a covered federal employee cannot also collect state workers’ compensation for the same injury. The CA-10 reminds the worker of this exclusivity, which prevents double-dipping but also forecloses state-law remedies.

The consequence is that even in worker-friendly states like California or New York, an injured federal employee must use FECA. A real example: David Park (the TSA officer) cannot file a California DWC-1 for his knee injury; CA-10 directs him to FECA only.

A common misconception is that dual filing is allowed if state benefits are higher. They are not. State agencies routinely deny federal-worker claims by citing § 8116(c).

FAQs

Is CA-10 a claim form?

No. CA-10 is an informational notice describing FECA rights and duties. The actual claim forms are CA-1 (traumatic injury), CA-2 (occupational disease), CA-7 (wage loss), and CA-5 (death benefits).

Do I have to sign CA-10?

Yes. Signing acknowledges receipt of the FECA rights notice and protects later equitable-tolling arguments before the ECAB if your agency mishandles the claim.

Can my supervisor refuse to give me CA-10?

No. Under 20 CFR § 10.11, the employing agency must furnish FECA notice to every injured worker; refusal can support an OWCP audit finding and equitable tolling.

Does CA-10 start my continuation-of-pay clock?

No. COP is triggered by a timely CA-1 filing within 30 days of injury, not by CA-10, which only documents notice of FECA rights.

Is electronic CA-10 in ECOMP valid?

Yes. ECAB and OWCP recognize ECOMP electronic acknowledgements as legally equivalent to a wet-ink signature under DOL e-signature policy.

Can a representative sign CA-10 for me?

Yes. A duly authorized representative with a signed Form OWCP-2519 on file may sign on the worker’s behalf, but the worker remains responsible for accuracy.

Will CA-10 affect my disability retirement?

No. FECA benefits and OPM disability retirement are separate; CA-10 only documents FECA notice and does not influence OPM eligibility.

Can I file CA-10 after the three-year deadline?

Yes, but only if you can show the agency failed to give notice or otherwise misled you, supporting equitable tolling under ECAB precedent like J.S. and Department of the Navy.

Does CA-10 replace state workers’ compensation?

Yes. Under 5 U.S.C. § 8116(c), FECA is the exclusive remedy for covered federal civilian employees, and CA-10 reminds workers they cannot also collect state benefits.

Where do I send a completed CA-10?

Yes, there is a specific destination: keep a personal copy and submit through ECOMP so the form lands in the correct OWCP district office tied to your agency code.