(a) Personal injury. In support of a claim for personal injury,
including pain and suffering, the claimant is required to submit the
following evidence or information:
(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 impairment, the
prognosis, period of hospitalization, if any, and any diminished earning
capacity. In addition, the claimant may be required to submit to a
physical or mental examination by a physician employed or designated by
the Department or another federal agency. A copy of the report of the
examining physician shall be made available to the claimant upon the
claimant's written request: Provided, That he or she has, upon request,
furnished the report referred to in the first sentence of this
subparagraph and has made, or agrees to make available to the
Department, any other physician's report previously or thereafter made
of the physical or mental condition which is the subject matter of the
claim.
(2) Itemized bills for medical, dental and hospital, or any other,
expenses incurred or itemized receipts of payment for such expenses.
(3) If the prognosis reveals the necessity for future treatment, a
statement of expected expenses for such treatment.
(4) 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 or part-time employee, and wages
or salary actually lost.
(5) If a claim is made for loss of income and the claimant is self-
employed, documentary evidence showing the amount of earnings lost. For
example, income tax returns for several years prior to the injury in
question and the year in which the injury occurred may be used to
indicate or measure lost income; a statement of how much it did or would
cost the claimant to hire someone else to do the same work he or she was
doing at the time of injury might also be used in measuring lost income.
(6) Any other evidence or information which may have a bearing on
either the responsibility of the United States for the personal injury
or the damages claimed.
(b) 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 the 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 name, address, birth date, kinship and marital status of
the decedent's survivors, including identification of those survivors
who were dependent for support upon the decedent at the time of his or
her death.
(4) Degree of support afforded by the decedent to each survivor
dependent upon him or her for support at the time of his or her death.
(5) Decedent's general physical and mental condition before his or
her 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 prior to 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 injury and death.
(8) Any other evidence or information which may have a bearing on
either the responsibility of the United States for the death or damages
claimed.
(c) Property damages. In support of a claim for injury to or loss of
property, real or personal, the claimant may be required to submit the
following evidence or information with respect to each item of property:
(1) Proof of ownership.
(2) A detailed statement of the amount claimed.
(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 where repair is not economical.
(5) Any other evidence or information which may have a bearing on
either the responsibility of the United States for the injury to or loss
of property or the damages claimed.
