Language selection

Government of Canada / Gouvernement du Canada

Search

Reserve Force – Compensation during a Period of Injury, Disease or Illness form – DND 2398

PROTECTED B (When completed)

Part I – Personal information

Service Number
Rank
Surname
Given name and initials
Date of Birth (yyyy-mm-dd)
MOS ID
Class of service when injury / illness occurred (A / B / C)
Member’s unit and UIC
Phone number
Email
Date and time of injury / illness
Place of accident

Part ll – Narrative

The Assisting Officer is to provide an explanation of the cause and contributing factors surrounding the injury, disease or illness. Attach a copy of the CF 98 if applicable. For any additional information please attach a letter.

Part III – Determination

Provide the following information (check the appropriate box).

  1. Was the member on duty at the time of the injury or illness? (if Yes, explain)
    Yes / No
  2. Was the injury / illness attributable to military service? (if Yes, explain). Provide substantiation, i.e. authorized sports, training schedule, etc.
    Explain

Part IV – Entitlement to compensation during a period of injury, disease or illness

If the member suffered and injury / illness which is considered to be attributable to the performance of military service, proceed and check the appropriate box.

  1. Did the member continue to receive Reserve pay and allowance until the end of the scheduled Reserve service during which the injury / illness occurred?
    Yes / No
    *If No, when and why did employment cease?
    Date of cessation of employment (yyyy-mm-dd)
    Reason

    Note: included CF 895 or CF 898 form for Class “A”, CF 899 for Class “B” or authority message from Class “C”.

  2. Was the member earning any pay, wages, salary or commission arising from civilian employment at the time of the injury or illness?
    Yes / No
    If Yes, complete Appendix 1 to Annex B

  3. (1) Was the member of a full-time student at the time of the injury?
    Yes / No
    If Yes, provide proof of registration.

    (2) If a full time student, was the member able to attend scheduled Class “A” training days?
    Yes / No
    If No, complete Annex D.

  4. I certify that the injured / ill member has been informed of the provisions of the Canadian Forces Members and Veterans Re-establishment and Compensation Act.

Part V – Assisting Officer’s certification

I am satisfied that this request for RFC is complete and accurate.

Rank, name and unit
Assisting Officer’s Signature
Telephone no.
Date (yyy-mm-dd)

Part VI – Commanding officer’s recommendation

I am satisfied that the information provided in this request for RFC is complete and accurate.

I recommend / I do not recommend
Rank Name and Initials
be paid compensation under CBI 210.72 for the following period:
From (yyyy-mm-dd) / to (yyyy-mm-dd)

Rank, name and unit
Commanding officer Signature
Telephone no.
Date (yyyy-mm-dd)

Part VII – Brigade/Group commander’s recommendation

Provide covering letter.

Part VIII – Command/Division Commander’s recommendation

Provide covering letter.

Annexes

ANNEX A

Medical Doctor’s Statement

  1. Authorization to release medical information.

    To be completed by the member:
    Service number
    Rank
    Name in full
    request the medical doctor to complete the information listed below pertaining to the injury / illness which was suffered on:
    Date (yyyy-mm-dd)

    I authorized its release to my Commanding Office, for the purpose of compensation during a period of injury, disease or illness. IAW CBI 210.72. I fully understand that this information will be kept confidential.
    Member’s signature
    Date (yyyy-mm-dd)

  2. Medical doctor’s statement

    To be completed be a medical authority

    1. What are the Medical Employment Limitations?
    2. B IS this injury, disease or illness attractable to military service?
      Yes / No / Unknown
    3. Sick leave
      From (yyyy-mm-dd) to (yyyy-mm-dd)
    4. CF 2018/CF H Svcs Chit attached
      Yes / No

    For military medical officer use only:
    Medical category
    V / CV / H / G / O / A

  3. Hospitalization

    1. Was the member admitted to a hospital?
      Yes / No
    2. Date for period of hospitalization
      From (yyyy-mm-dd) to (yyyy-mm-dd)

Medical treatment and period of incapacitation

  1. Period(s) of incapacitation

    I certify that (__) is/was undergoing medical treatment during the following period and that this injury / illness is attributable to military service:
    From (yyyy-mm-dd) to (yyyy-mm-dd) and:

    1. Is medically fir or able to return to full time military duties IAW MELs.
      Yes / No
    2. Is able to return or seek gainful civilian employment.
      Yes / No
    3. Is able to resume full time studies.
      Yes / No / N/A

  2. Return to Duty (RTD)

    Is the member recommended for participation in a CF RTD Program?
    Yes / No

  3. Prognosis

    Definition of disability
    The member’s employment limitations are beyond the minimal medical category for his MOSID or are in breach of U of S.

    1. What is the reassessment date: (yyyy-mm-dd)
    2. What is the projected end date of disability: (yyyy-mm—dd)
    3. AR/MEL status:
      Comments
      Print / Rank, name, initials
      Medical doctor’s signature
      Telephone no.
      Date (yyyy-mm-dd)

ANNEX B

Member’s Statement

I, do hereby declare that I was incapacitated, as indicated in the medical Statement at Annex A.

  1. Were you gainfully employed as a civilian prior / during the period of incapacitation indicated at Annex A?
    Yes / No
    1. I was employed as a civilian prior to my injury or illness.
      Yes / No
    2. I was employed as a civilian during the period of incapacitation indicated at Annex A.
      Yes / No
  2. Are you a full time student?
    Yes / No
    Name of institution
  3. Are you currently participating in a CAF Return to Duty Program prescribed by your doctor?
    Yes / No
    1. I certify that I have been informed of the provision of the Government Employees Compensation Act and that I may only receive compensation under one of the two programs available to me.
    2. Have you applied for benefits under the GECA program?
      Yes / No
  5. Are you a Regular Force Annuitant?
    Yes / No

General Information – Disability award

If you feel that you are suffering or might suffer from any long term disability arising out of injuries, or any other conditions related to you military service: please contact Veterans Affairs Canada (VAC) at 1-866-522-2122, to initiate an application for disability benefits, or visit the Veterans Affairs Canada website.

SS, rank, name and unit
Member signature
Telephone no.
Date (yyyy-mm-dd)

APPENDIX 1 TO ANNEX B

Employer’s statement (To be completed by the Assisting Officer)

The assisting officer is responsible to meet the employer and obtain the information required along with the signature of the employer, Details of sick leave benefits or payments make through contributory insurance scheme should be included in this statement.

    1. Name of Employee
    2. Date of Injury/illness (yyyy-mm-dd)
    3. Self Employed?
      Yes / No
    4. Job Title / Occupation (at the time of the injury or illness – do not use abbreviations)
    5. Length of time in this position while working for you
  2. Lost time – No lost time
    Please choose one of the following indicators. After the day of the accident/awareness of the illness, this worker:
    • Returned to his/her regular job and has not lost any time and or earnings.
    • Has lost time and/or earnings.
      • Date of last day worked (yyyy-mm-dd)
      • Date of returned to work (yyyy-mm-dd)
  3. Base Wages/Employment Information
    • Full-time Employee
    • Part-time Employee
    • Date of injury (yyyy-mm-dd)
    • Regular rate of pay $:
      • per hour
      • per day
      • per week
      • other

    Signature of member’s employer or representative
    Date (yyyy-mm-dd)
    Print / Name and initials
    Print / Designation
    Telephone number (with area code)

    4. Note: This form is only to be completed when the Reservist has civilian employment.

ANNEX C

Accounting Officer’s statement

This annex must be completed by the person responsible for maintain the injured/ill member’s pay documents. This statement must include all pay the member received from the date of injury to the end of the period of incapacitation.

  1. Date of injury (yyyy-mm-dd)
    Rank / name
    Pay increment
    Rate of Pay

  2. I certify from the date of injury and for the period of incapacitation for compensation is being claimed,
    Rank, name, initials
    received reserve pay as follows:

    • Class of Service
    • Pay level
    • Rate
    • Dates
    • (yyyy-mm-dd)
    • Reason (see note)
    • Amount
    • Total

    Note: Indicate reason why member received his reserve pay during period of incapacitation (e.g. medical appointment, physic, RTD, parade, training, etc.)

    • Accounting officer signature
    • Date (yyyy-mm-dd)
    • Print / Rank, name and initials
    • Print / Unit
    • Telephone number (with area code)

ANNEX D

Statement of member’s lost Class “A” training days

This annex is to be completed if the member is a dull-time student unable to parade with his/her unit during scheduled unit training and / or parade nights. This annex must be verified against the Accounting officer’s statement, Annex C.

Checklist

To be completed by the assisting officer

The following items are enclosed with this application:
Item

Page details

Date modified: