Form CA-6 Official Superior's Report of Employee's Death

Form CA-6 or the "Official Superior's Report Of Employee's Death" is a form issued by the U.S. Department of Labor.

Download a PDF version of the Form CA-6 down below or find it on the U.S. Department of Labor Forms website.

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I
*
0 Male
/
0 Female
I
0 AM
0 AM
0 PM
c] AM
0 PM
0
0 No (if No, explain)
0 yes 0
0 Yes ci
I
0 CSBS 0 F E R S 0 O t h e r
/
1
I
0
0
Official Superior’s Report of
U.S. Department of Labor
Office of Workers’ Compensation Programs
Employee’s Death
*
3.
1. Name of Deceased Employee (Last, first. middle)
2. Date of Birth (M
., day, year)
4. Social Security N
,
O
O
6. OWCP Agency Code
7. OSHA Site Code
5. Department or Agency
8. Name and Address of Reporting Office
9. Name and Office Phone Number of Employee’s Official Superior
10. Date and Hour of Injury
11. Date and Hour of Death
12. Date and Hour Employee’s Pay Stopped
(M
., day, year)
(M
., day, year)
(M
., day, year)
O
O
O
c l P M
13. Describe how injury occurred
14. Was employee in perfo
rmance of duty when injury occurred?
Yes
:
17.
lmmediate cause of death (Attach medical
15. Location where Injury occurred
16. Location where death occurred
and autopsy report if available)
18. Employee’s pay rate as of
b. Subsistence
a. Base pay
c. Quarters
d. Other
A. Date of injury
$
$
S
$
per
per
per
per
B. Date pay stopped
$
S
S
S
per
per
per
per
19. Did employee work in positron held at tim
of injury
20. If answer to 19 is no, would position have afforded employment
for a full eleven months immediately prior to the injury?
for eleven months except for the injury?
No
No
21. Did employee receive leave pay for any part of period from time pay stopped to
22. a. Occupation code
date of death? (Give inclusive dates)
b. Type code
c. Source code
From
To
-
OWCP use
NOI code
23. Did employee receive continuation of pay (COP) during perrod pnor to death?
i
24.
If employee was enrolled in Health
cop
a. Pay rate used for COP
b. Inclusive dates of
Benefit Plan for self and family, show
HBS Code Number:
From
To
$
per
25. Show date through which HBS deductions
26. ldentify employee’s Federal Retirement Plan:
27. If employee received medical care prior
were last made (M
., day, year)
to death, give name and address of
O
attending physician
29. Give name and address of the attorney representing the
28. If injury was caused by a third party, give
survivors if legal action is instituted against the third party
name and address of third party
I
$
31. If employee was a member of the Armed Services
the United States , show:
benefits been filed with the
32. Has claim for survivor’s
Office of Personnel Management?
Branch of Service:
Yes
No
Serial No. (If known)
33. Name and address of employee’s spouse or next of kin (Show relationship, if other than spouse)
35. Title
/
34. Signature of Official Superior
36. Date (M
., day, year)
O
Form CA-6
Rev. Jan. 1997
I
*
0 Male
/
0 Female
I
0 AM
0 AM
0 PM
c] AM
0 PM
0
0 No (if No, explain)
0 yes 0
0 Yes ci
I
0 CSBS 0 F E R S 0 O t h e r
/
1
I
0
0
Official Superior’s Report of
U.S. Department of Labor
Office of Workers’ Compensation Programs
Employee’s Death
*
3.
1. Name of Deceased Employee (Last, first. middle)
2. Date of Birth (M
., day, year)
4. Social Security N
,
O
O
6. OWCP Agency Code
7. OSHA Site Code
5. Department or Agency
8. Name and Address of Reporting Office
9. Name and Office Phone Number of Employee’s Official Superior
10. Date and Hour of Injury
11. Date and Hour of Death
12. Date and Hour Employee’s Pay Stopped
(M
., day, year)
(M
., day, year)
(M
., day, year)
O
O
O
c l P M
13. Describe how injury occurred
14. Was employee in perfo
rmance of duty when injury occurred?
Yes
:
17.
lmmediate cause of death (Attach medical
15. Location where Injury occurred
16. Location where death occurred
and autopsy report if available)
18. Employee’s pay rate as of
b. Subsistence
a. Base pay
c. Quarters
d. Other
A. Date of injury
$
$
S
$
per
per
per
per
B. Date pay stopped
$
S
S
S
per
per
per
per
19. Did employee work in positron held at tim
of injury
20. If answer to 19 is no, would position have afforded employment
for a full eleven months immediately prior to the injury?
for eleven months except for the injury?
No
No
21. Did employee receive leave pay for any part of period from time pay stopped to
22. a. Occupation code
date of death? (Give inclusive dates)
b. Type code
c. Source code
From
To
-
OWCP use
NOI code
23. Did employee receive continuation of pay (COP) during perrod pnor to death?
i
24.
If employee was enrolled in Health
cop
a. Pay rate used for COP
b. Inclusive dates of
Benefit Plan for self and family, show
HBS Code Number:
From
To
$
per
25. Show date through which HBS deductions
26. ldentify employee’s Federal Retirement Plan:
27. If employee received medical care prior
were last made (M
., day, year)
to death, give name and address of
O
attending physician
29. Give name and address of the attorney representing the
28. If injury was caused by a third party, give
survivors if legal action is instituted against the third party
name and address of third party
I
$
31. If employee was a member of the Armed Services
the United States , show:
benefits been filed with the
32. Has claim for survivor’s
Office of Personnel Management?
Branch of Service:
Yes
No
Serial No. (If known)
33. Name and address of employee’s spouse or next of kin (Show relationship, if other than spouse)
35. Title
/
34. Signature of Official Superior
36. Date (M
., day, year)
O
Form CA-6
Rev. Jan. 1997
Instructions for Completing Form CA-6
When a Federal employee dies as a result of injury in performance of duty or because of an
employment related disease, the death should be reported on this form. This form eliminates
the need to complete and file the official superior’s report on Form CA-l, Federal Employee’s
Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation or Form CA-2,
Federal Employee’s Notice of Occupational Disease and Claim for Compensation.
The form is to be completed by the deceased employee’s official superior or other authorized
official of the employing agency. It should be accompanied by a certified copy of the death
certificate. when submitted to OWCP.
Form CA-5 or CA-5b should be supplied to the employee’s spouse or next of kin.
If additional space is required, attach separate sheets and number the answers to correspond
with the items on the form.
For additional information about death benefits, see 20 CFR 1.1 and/or Chapter 810, Injury
Compensation, Federal Personnel Manual.
Box 22a (Occupation Code), Box 22b (Type Code),
Box 22c (Source Code), OSHA She Code
The Occupational Safety and Health Administration (OSHA) requires all employing agencies to
complete these items when reporting an injury. The proper codes may be found in OSHA
Booklet 2014, Recordkeeping and Reporting Guidelines.
OWCP Agency Code
This is a four digit (or four digit plus two letter) code used by OWCP to identify the employing
agency. The proper code may be obtained from your personnel or compensation office, or by
contacting OWCP.

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