[Code of Federal Regulations]
[Title 40, Volume 31]
[Revised as of July 1, 2007]
From the U.S. Government Printing Office via GPO Access
[CITE: 40CFR1620.5]

[Page 945-946]
 
                   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 946]]

    (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.