CA2 Timeline and Bulletpoint Form

Timeline & Bulletpoint Patient Form

Please complete the below form if you have filed a CA-2 Occupational Disease work injury. Please follow the instructions closely and reach out to Federal Injury Group at 866-981-4581 with any questions.
Patient & Injury Identification
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date Completing This Form

MonthDayYear
Date
Date of Injury:

MonthDayYear
Date
Employer/Agency
USPS, VA, TSA, etc
Body Part(s) Affected in CA-2 Occupational Disease Work-Related Injury. Please check all that apply:

Other
In a few sentences, please provide a BRIEF description of your work-related injury and how it happened:

Please limit to 3-4 short sentences or 100 words or less.0/100
Timeline of Major Events
Please do your best to answer the questions below to provide a timeline of key events related to your current job and your work-related injury.
1. Please state your job title and when you started the job related to your CA-2 work-related injury:
Ex. USPS City Letter Carrier - June 2023, USPS Rural Carrier - May 2025
2. Have you switched jobs or job duties over the years?
If yes, please list when and what the jobs/job duties were as they relate to your work-related injury:
Ex. June 2020: Started USPS as regular carrier, February 2021: Pain started in R arm, March 2021: Began taking less shifts, etc
3. Have you had any previous injuries to the body parts your are claiming on this injury?
If yes, please list the previous injuries to the related body parts:
Ex. trip and fall on L knee back in May 2024
4. When did the symptoms/pain start? Please include dates & the areas that were/are affected:
Ex. June 2020 - pain started in R knee, July 2020 - pain began in R ankle, etc
5. When did the symptoms worsen? Did they improve at all? Please include dates & how your symptoms changed as time continued:
Ex. May 2025 - pain in R knee started, June 2025 - pain in R knee got worse and pain in L knee started, July 2026 - asked supervisor to modify duties, etc.
6. Please list the doctors and locations you were seen at before you came to a clinic of Federal Injury Group: *Please put 'N/A' if you have not been anywhere else before coming to a clinic of Federal Injury Group*
Ex. February 2026 - visit an urgent care for sharp pain, March 2026 - referred to orthopedic doctor at xyz clinic, May 2026 - did PT at xyz clinic as referred to by Dr. John Doe, etc.
7. What treatments, if any, did you have for this work-related injury? *Please put 'N/A' if you have not had any treatments for this work-related injury*
Ex. visiting a pain management clinic, got an XRAY or MRI performed, tried PT at xyz clinic, etc.
8. Were you prescribed any medications for this work-related injury?
If yes, please list all medications with dosages below:
9. At the beginning of this form, you listed Date as the Date of Injury:
Please include a brief description as to why you chose this date:
Ex. This is the date that I noticed the pain being consistent, this is the date I spoke with Dr. John Doe and was told I have an injury, etc.
10. Were you working at full duty at the time of injury?
If no, what were those modified duty restrictions?
11. Have you missed any time from work due to this injury?
If yes, please include the dates or date ranges:
12. What was the last day that you worked?

MonthDayYear
Date
Job Duties with Durations
Please create a bulletpoint list of duties that are specific to your route or job and how long you performed those duties for. These are job-related tasks that you do every day:
Example Bulletpoint List:
- Case route for about 1.5 hours in the morning
- Leave office and start curbside delivery for about 2.5 hours
- Park and loop for about 3 hours
- 5-10 heavy packages to deliver to a business
- 10,000 - 15,000 steps per day
- Extra routes, responsibilities, etc.
Acknowledgment
Confirmation
Signature
Should be Empty:

Timeline & Bulletpoint Patient Form

Patient & Injury Identification

Timeline of Major Events

Job Duties with Durations

Acknowledgment