FECA Medical Report Forms, Claim for Compensation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ca-17 FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Available
1215-0103 OMB Form 83-12.doc	Supplementary Document	Uploaded 2008-07-17	Available
Supporting Statement for 1215-0103 (Various CA Forms) July 15 2008.doc	Supporting Statement A	Uploaded 2008-07-15	Available
THE PRIVACY ACT OF 1974.doc	Supplementary Document	Uploaded 2008-03-14	Available
DOL_GOVT-1.doc	Supplementary Document	Uploaded 2008-03-14	Available
Compensation Act.doc	Supplementary Document	Uploaded 2008-03-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0103	ICR Reference No: 200803-1215-005
Status: Historical Active	Previous ICR Reference No: 200507-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: FECA Medical Report Forms, Claim for Compensation
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/08/2008
	Date Received in OIRA: 08/07/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2011	36 Months From Approved	10/31/2008
Responses	2,635	0	302,485
Time Burden (Hours)	273	0	30,748
Cost Burden (Dollars)	1,186	0	121,000

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Abstract: These forms are used for filing claims for wage loss or 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 USC 8101 et.seq.

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Authorizing Statute(s): US Code: 5 USC 8101 et.seq Name of Law: Federal Employees Compensation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 20720	04/16/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 46036	08/07/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
FECA Medical Report Forms, Claim for Compensation	CA-7, CA-17, CA-1331, CA-1332, OWCP-5A, ca-16, owcp-5b, owcp-5c, ca-20, ca-17	Duty Status Report ,   Attending Physicians Report ,   Authorization for Examination and/or Treatment ,   Claim for Compensation ,   Duty Status Report ,   Outline for Otologic Testing ,   Work Capacity Evaluation ,   Work Capacity Evaluation ,   Work Capacity Evaluation Form ,   Authorization to doctor for audiologic and otologic evaluation

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ICR Summary of Burden

table that charts list of burden

	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	2,635	302,485	0	-291,905	-7,945	0
Annual Time Burden (Hours)	273	30,748	0	-30,220	-255	0
Annual Cost Burden (Dollars)	1,186	121,000	0	-131,357	11,543	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The responses from the respondents decreased from 302,485 to 294,540, which is an adjustment of -7,945 responses. Accordingly, the burden hours decreased from 30,748 to 30,493 which is an adjustment of -255 burden hours. There was an increase in respondent costs due to the increase in wages for Administrative Support Occupations. In addition, the maintenance and operation costs increased from $121,000 to $132,543 due to postage and mailing costs.

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Annual Cost to Federal Government: $879,464

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/07/2008

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