FECA Medical Report Forms

ICR 199908-1215-002

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
13768 Migrated
ICR Details
1215-0103 199908-1215-002
Historical Active 199807-1215-005
DOL/ESA
FECA Medical Report Forms
Extension without change of a currently approved collection   No
Regular
Approved without change 10/14/1999
Retrieve Notice of Action (NOA) 08/18/1999
Approved consistent with clarifications in DOL memo of 10-7-99. DOL will report in September 2000 and September 2001 on the progress it has made in facilitating the electronic submission of these forms.
  Inventory as of this Action Requested Previously Approved
08/31/2002 08/31/2002 10/31/1999
302,628 0 441,855
30,766 0 43,414
109,000 0 154,000

These forms are used for filing claims for wage loss of permanent impairment due to a Federal employment-related injury and to obtain necessary medical documentation to determine whether a claimant is entitled to benefits under the Federal Employees Compensation Act (FECA), 5 U.S.C. 8101 et seq.

None
None


No

1
IC Title Form No. Form Name
FECA Medical Report Forms CA-7, CA-16-17, CA-20, CA-1090, CA-1303, CA-1305-1306, CA-1314, CA-1316, CA-1331-1332, CA-1336

  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 302,628 441,855 0 0 -139,227 0
Annual Time Burden (Hours) 30,766 43,414 0 0 -12,648 0
Annual Cost Burden (Dollars) 109,000 154,000 0 0 -45,000 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.
08/18/1999


© 2024 OMB.report | Privacy Policy