[Code of Federal Regulations]

[Title 40, Volume 31]

[Revised as of July 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 40CFR1620.5]



[Page 943-944]

 

                   TITLE 40--PROTECTION OF ENVIRONMENT

 

       CHAPTER VI--CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD

 

PART 1620_ADMINISTRATIVE CLAIMS ARISING UNDER THE FEDERAL TORT CLAIMS 

ACT--Table of Contents

 

Sec.  1620.5  Administrative claim; evidence and information to be 

submitted.



    (a) Death. In support of a claim based on death, the claimant may be 

required to submit the following evidence or information:

    (1) An authenticated death certificate or other competent evidence 

showing cause of death, date of death, and age of the decedent.

    (2) Decedent's employment or occupation at time of death, including 

his or her monthly or yearly salary or earnings (if any), and the 

duration of his or her last employment or occupation.

    (3) Full names, addresses, birth date, kinship and marital status of 

the decedent's survivors, including identification of those survivors 

who were dependent on support provided by the decedent at the time of 

death.

    (4) Degree of support afforded by the decedent to each survivor 

dependent on him or her for support at the time of death.

    (5) Decedent's general physical and mental condition before death.

    (6) Itemized bills for medical and burial expenses incurred by 

reason of the incident causing death, or itemized receipts of payment 

for such expenses.

    (7) If damages for pain and suffering before death are claimed, a 

physician's detailed statement specifying the injuries suffered, 

duration of pain and suffering, any drugs administered for pain, and the 

decedent's physical condition in the interval between injuries and 

death.

    (8) True and correct copies of relevant medical treatment records, 

laboratory and other tests, including X-Rays, MRI, CT scans and other 

objective evidence of medical evaluation and diagnosis, treatment of 

injury/illness, and prognosis, if any had been made.

    (9) Any other evidence or information that may have a bearing on 

either the responsibility of the United States for the death or the 

amount of damages claimed.

    (b) Personal injury. In support of a claim for personal injury, 

including pain and suffering, the claimant may be required to submit the 

following evidence or information:



[[Page 944]]



    (1) A written report by the attending physician or dentist setting 

forth the nature and extent of the injury, nature and extent of 

treatment, any degree of temporary or permanent disability, the 

prognosis, period of hospitalization, and any diminished earning 

capacity. If damages for pain and suffering are claimed, a physician's 

detailed statement specifying the duration of pain and suffering, a 

listing of drugs administered for pain, and the claimant's general 

physical condition.

    (2) True and correct copies of relevant medical treatment records, 

laboratory and other tests including X-Rays, MRI, CT scans and other 

objective evidence of medical evaluation and diagnosis, treatment 

injury/illness and prognosis.

    (3) The claimant may be required to submit to a physical or mental 

examination by a physician employed by CSB or another Federal agency. On 

written request, CSB will make available to the claimant a copy of the 

report of the examining physician employed by the United States, 

provided the claimant has furnished CSB with the information noted in 

paragraphs (b)(1) and (b)(2) of this section. In addition, the claimant 

must have made or agrees to make available to CSB all other physicians' 

reports previously or thereafter made of the physical or mental 

condition that is subject matter of his or her claim.

    (4) Itemized bills for medical, dental, and hospital expenses 

incurred, and/or itemized receipts of payment for such expenses.

    (5) If the prognosis reveals the necessity for future treatment, a 

statement of the expected treatment and the expected expense for such 

treatment.

    (6) If a claim is made for loss of time from employment, a written 

statement from his or her employer showing actual time lost from 

employment, whether he or she is a full-time or part-time employee, and 

wages or salary actually lost.

    (7) If a claim is made for loss of income and the claimant is self-

employed, documentary evidence showing the amount of earnings actually 

lost.

    (8) Any other evidence or information that may have a bearing on 

either the responsibility of the United States for the personal injury 

or the damages claimed.

    (c) Property damage. In support of a claim for damage to or loss of 

property, real or personal, the claimant may be required to submit the 

following evidence or information:

    (1) Proof of ownership of the property.

    (2) A detailed statement of the amount claimed with respect to each 

item of property.

    (3) An itemized receipt of payment for necessary repairs or itemized 

written estimates of the cost of such repairs.

    (4) A statement listing date of purchase, purchase price, and 

salvage value.

    (5) Photographs or video footage documenting the damage, including 

photographs showing the condition of the property at issue both before 

and after the alleged negligence or wrongful act or omission.

    (6) Any other evidence or information that may have a bearing on 

either the responsibility of the United States for the damage to or loss 

of property or the damages claimed.