FECA Medical Report Forms, Claim for Compensation

ICR 200803-1215-005

OMB: 1215-0103

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2008-07-17
Supporting Statement A
2008-07-15
Supplementary Document
2008-03-14
Supplementary Document
2008-03-14
Supplementary Document
2008-03-14
IC Document Collections
ICR Details
1215-0103 200803-1215-005
Historical Active 200507-1215-001
DOL/ESA
FECA Medical Report Forms, Claim for Compensation
Extension without change of a currently approved collection   No
Regular
Approved without change 09/08/2008
Retrieve Notice of Action (NOA) 08/07/2008
  Inventory as of this Action Requested Previously Approved
09/30/2011 36 Months From Approved 10/31/2008
2,635 0 302,485
273 0 30,748
1,186 0 121,000

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.

US Code: 5 USC 8101 et.seq Name of Law: Federal Employees Compensation Act
  
None

Not associated with rulemaking

  73 FR 20720 04/16/2008
73 FR 46036 08/07/2008
No

  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
No
No
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.

$879,464
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Carol Adams 904 357-4747 ext. 74105

  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.
08/07/2008


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