This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.
The latest form for Notice of Recurrence expires 2021-01-31 and can be found here.
Document Name |
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Form and Instruction |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supporting Statement A |
Approved without change |
Revision of a currently approved collection | 2023-12-06 | |
Extension without change of a currently approved collection | 2020-10-30 | ||
Approved without change |
Revision of a currently approved collection | 2017-08-31 | |
Approved without change |
Revision of a currently approved collection | 2014-06-25 | |
Approved without change |
Revision of a currently approved collection | 2011-05-02 | |
Approved without change |
Extension without change of a currently approved collection | 2010-03-12 |