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Feca Medical Report Forms
FECA MEDICAL REPORT FORMS
OMB: 1215-0103
IC ID: 168479
OMB.report
DOL/ESA
OMB 1215-0103
ICR 198503-1215-004
IC 168479
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0103 can be found here:
2008-08-07 - Extension without change of a currently approved collection
2005-07-01 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
FECA MEDICAL REPORT FORMS
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CA-16, 17
No
No
Form
20, 28A, 28B
No
No
Form
1090, 1302
No
No
Form
1303, 1304
No
No
Form
1306, 1308
No
No
Form
1316, 1331
No
No
Form
OWCP
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
480,350
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
480,350
0
0
0
0
480,350
Annual IC Time Burden (Hours)
216,700
0
0
0
0
216,700
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.