Submit the completed form to your employing agency's appropriate office. If filing by mail, send it to the address provided by your agency. If submitting electronically, use the agency's online submission form or email it to the designated address. Ensure all required fields are filled and the necessary signatures are obtained. It is advisable to keep a copy of the submitted form for your records. Timely submission is crucial to avoid delays in the processing of your claim.

Ensure the form is submitted within 30 days of the date you first realized the disease or illness was caused or aggravated by your employment.

The purpose of this form is to report and claim compensation for occupational diseases or illnesses related to federal employment. Employees are required to provide personal information, details of their employment, and specific information about the disease or illness. Supervisors are also required to complete sections of the form to provide verification and additional details.

• 1. Name of Employee: The full name of the employee, including last, first, and middle names.
• 2. Email Address: The employee's email address for correspondence.
• 3. Date of Birth: The employee's date of birth.
• 4. Gender: The employee's gender.
• 5. Home Telephone: The employee's home telephone number.
• 6. Home Mailing Address: The employee's home mailing address including street, city, state, and ZIP code.
• 7. Grade: The employee's grade or level at the time of the last exposure.
• 8. Employee's Occupation: The employee's occupation or job title.
• 9. Location of Work: The location where the employee worked when the disease or illness occurred.
• 10. Date First Aware of Disease: The date when the employee first became aware of the disease or illness.
• 11. Date First Realized Relationship to Work: The date when the employee first realized the disease or illness was related to their employment.
• 12. Nature of Disease or Illness: A description of the nature of the disease or illness.
• 13. Reason for Delay: Explanation for any delay in filing the notice and claim.
• 14. Employee Signature: The employee's signature certifying the accuracy of the information provided.
• 15. Supervisor's Report: The supervisor's section providing additional details and verification.

Failure to submit this form may result in delayed or denied compensation benefits. Proper and timely submission is crucial for the processing of your claim.

• Loss of Benefits: Failure to submit the form on time may result in the loss of compensation benefits.
• Delayed Processing: Submitting the form late can cause delays in the processing of your claim.

• 1. Reporting Occupational Disease: Use this form to report a disease or illness that you believe is related to your employment.
• 2. Claiming Compensation: Submit this form to claim compensation for medical treatment and wage loss due to the occupational disease.