MEDICAL REPORT FORMS

ICR 198211-1215-003

OMB: 1215-0103

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
122147 Migrated
ICR Details
1215-0103 198211-1215-003
Historical Active 198206-1215-003
DOL/ESA
MEDICAL REPORT FORMS
Revision of a currently approved collection   No
Regular
Approved without change 12/27/1982
Retrieve Notice of Action (NOA) 11/10/1982
  Inventory as of this Action Requested Previously Approved
06/30/1983 06/30/1983 12/31/1982
608,500 0 608,000
151,708 0 151,708
0 0 0

THE INFORMATION OBTAINED THROUGH THE USE OF THE FORMS IN QUESTION IS NECESSARY TO DETERMINE WHETHER OR NOT A FEDERAL EMPLOYEE WHO HAS FILED CLAIM UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)(8101 ET SEQ) IS ENTITLED TO COMPENSATION UNDER THE FECA.

None
None


No

1
IC Title Form No. Form Name
MEDICAL REPORT FORMS CA-16,17,20,, 28,1090,, 1302,1303,, 1304,1306,, 1308,1316,, 1331,, OWCP-5

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 608,500 608,000 0 500 0 0
Annual Time Burden (Hours) 151,708 151,708 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/10/1982


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