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Click ‘Get Form’ to open it in the editor.
Begin with Part A, where the employee must fill in their name, date of birth, and Social Security Number. Ensure accuracy as this information is crucial for identification.
Continue by providing details about the recurrence, including dates and circumstances. Use clear language to describe how the recurrence relates to the original injury.
In Part B, if applicable, have the supervisor or compensation specialist complete their section. This includes confirming details about the employee's duty station and any medical care authorized.
If you are no longer employed with the Federal Government, complete Part C by listing previous employers and job titles since leaving your last position.
Review all entries for completeness and accuracy before submitting. Utilize our platform’s features to save your progress and make edits as needed.
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