SUGGESTED FORMAT FOR NARRATIVE MEDICAL REPORT
IN SUPPORT OF AN FECA CLAIM (TRAUMATIC OR
OCCUPATIONAL DISEASE)
--Patient's name and address
--OWCP file number (if known)
1) Patient's history of injury/injuries or disease/illness. This is very important and should consist of a
written statement by the physician reflecting the physician's knowledge of the injury/injuries or -if a
disease/illness--the conditions of the employee's employment. It is essential that the physician first be
furnished with a written statement from the employee describing the injury/injuries, or conditions of
employment (the employee should be as specific as possible), so that the physician's statement might
reflect a true history of the injury/injuries or disease/illness. ·
a. --Date{s) of examination and/or treatments.
b. Period of hospitalization, if any.
c. Tests given, findings and results (X-rays, lab tests, EKG, EMG, etc.).
2. Definitive diagnosis {no impressions).
3. Opinion: was condition caused, permanently or temporarily aggravated, or accelerated by
injury/injuries or conditions of employment described by employee.
4. Medical reasons for opinion, i.e., how did-the physician, from a medical point of view, arrive at
the opinion? This is very important and should be as specific as possible-and should explain how
any test results may have formed the basis for the opinion. ·
5. Period of disability; the extent of disability during the period or periods claimed. This should
specify whether the disability was total or partial;. and if partial (as opposed to total disability for
work as a letter carrier), the work limitations involved in working in a partially disabled
condition. 1 Permanent disability; is this now present or anticipated? Explain.
a. Prognosis
b. Recommendations for future medical care.
c. Signature of physician; show specialty and if Board-Certified.
Important Information:
1. The physician’s assertion that he or she has read the employee statement and is exclusively
using the work factors described in the statement as a basis for his or her medical discussion
and opinion.
2. A definitive diagnosis stated in definite and clear language (speculative language such as
“might have caused the condition” is not sufficient).
3. A definitive statement that the claimed condition that has been diagnosed was caused,
aggravated, accelerated or precipitated by the work factors in the employee’s statement;
and whether such resultant condition is temporary or permanent.
4. The physician must provide medical reasons for his or her opinion that the work factors
caused the condition diagnosed. The medical relationship between the diagnosis and the
work factors must be outlined in positive, definitive language, and any tests results must be
included to support the relationship. This is most often included in the Physician’s
Comment or Summary section of the medical report.
5. The extent of the disability must be described (whether the disability is total or partial); and
if the disability is partial, the work limitations must be outlined for the employee while
working during the time of disability. The period of time the claimant will be partially or
totally disabled must be defined. This is most likely indicated by the GAF (Global
Assessment of Functioning) in the physician’s diagnosis.
Accepted Factors of Employment
SUGGESTED FORMAT FOR NARRATIVE MEDICAL REPORT
IN SUPPORT OF AN FECA CLAIM (TRAUMATIC OR
OCCUPATIONAL DISEASE)
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Stress caused by efforts to perform regularly and specially assigned job duties
Stress caused by violations of rules, regulations, policies or procedures
Stress caused by errors or abuses of discretion in handling administrative or personnel
matters
A physician’s opinion supporting causal relationship between a claimant’s disability and a specific
employment incident or factors of employment is not dispositive on the issue of causal relationship simply
because it is rendered by a physician. To be probative value to an employee’s claim, the physician must
provide rationale for the opinion reached. Where no such medical rationale is present the medical
opinion is of diminished probative value.
OWCP lingo, the term causal relationship means approximately caused. To prove that the disability,
illness or disease was approximately caused by the on-the- job injury or conditions at work, you must
show that the disability, illness or disease was either directly caused by the injury or employment
conditions or that the disability, illness or disease was closely related to, as a result of, or following the
injury or employment conditions.
Complainant contacted an EEO counselor concerning alleged workplace harassment and
sought a transfer as a remedy, referencing her medical condition. The Agency processed
the matter as a reasonable accommodation request only and not as a request to initiate the
EEO process.