OMB No. 1240-0046
Expires: 08/31/2026
INSTRUCTIONS TO PHYSICIAN FOR COMPLETING FORM CA-20, ATTENDING PHYSICIAN'S REPORT
Box 1 Enter the patient's full name
Box 2 If not prepopulated, enter the OWCP File Number provided to you by the patient. If unknown, leave blank.
Box 3 Enter the first known date this patient sought treatment for the work injury.
Box 4 Enter the date of this examination (i.e. the examination upon which your findings on the form are based).
Box 5 Provide an explanation as to how the patient's injury or disease occurred. Be as specific as possible.
Box 6 Detail the patient's objective findings on physical examination as related to the work injury noted in Box 5. Include results of
any diagnostic testing performed. Also, please reference any pre-existing injury or condition to the body part(s) affected by
the work injury.
Box 7 Provide specific diagnoses of each medical condition connected to the work injury. Please note that “pain” is not a
compensable diagnosis under the FECA.
Box 8 Provide corresponding ICD codes for each medical condition noted in Box 7.
Box 9 Address whether the work injury noted in Box 5 is causally connected in any way to the diagnoses in Box 7. Your answer
must be fully explained to be accepted by OWCP. Note that there is no apportionment under the FECA and any
contribution from work factors is compensable. Types of causal relationship under the FECA include:
Direct Causation. This type of relationship occurs when the injury or factors of employment, through a natural and unbroken
sequence, result in the condition claimed.
Aggravation. This type of relationship occurs if a pre-existing condition is worsened, either temporarily or permanently, by the
injury or factors of employment. If you believe the work injury aggravated a pre-existing condition, please indicate whether
such aggravation is temporary or permanent and if temporary, when the aggravation ceased or is expected to cease.
Acceleration. An employment-related injury or illness may hasten the development of an underlying condition, and
acceleration is said to occur when the ordinary course of the disease does not account for the speed with which a condition
develops.
Precipitation. A latent condition which would not have become manifest but for the employment is said to have been
precipitated by the injury/factors of the employment.
You may also include any consequential conditions that resulted from the initial work injury or disease. Under the FECA, a
subsequent injury, whether an aggravation of the original injury or a new and distinct injury, is compensable if it is the direct
and natural result of a compensable primary injury.
Box 10 Indicate the patient's current disability status:
Totally disabled: The claimant is unable to perform any and all work. Provide the date disability commenced and the date of
anticipated return to regular or modified work.
Partially disabled, The claimant is incapable of performing the job held when injured, but is capable of some work. Provide the
date disability commenced and the date of anticipated return to regular duty work.
Not disabled: The claimant is capable of performing the job held when injured. Indicate any previous dates of disability.
Box 11 If you stated the patient was partially disabled in Box 10, please indicate the extent of physical limitations and the type of work
that could reasonably be performed with these limitations. A link is provided to Form OWCP-5c, Work Capacity Evaluation,
for orthopedic conditions if you would prefer to provide work capacity information separately. The OWCP website at https://
www.dol.gov/agencies/owcp/FECA/regs/compliance/forms also has work capacity evaluation forms for psychiatric
(OWCP-5a) and cardiac (OWCP-5b) conditions if needed.
Box 12 If you have any additional remarks regarding this patient's work injury, please provide here. If not, leave blank.
Page 2CA-20 (Revised 08/2023)