OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

FECA Medical Report Forms, Claim for Compensation

IC 13770 under ICR 200803-1215-005 · OMB 1215-0103.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form ca-17
Duty Status Report FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form CA-7
Claim for Compensation FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form CA-17
Duty Status Report FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form CA-1331
Authorization to doctor for audiologic and otologic evaluation FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form CA-1332
Outline for Otologic Testing FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form OWCP-5A
Work Capacity Evaluation FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form owcp-5b
Work Capacity Evaluation FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form owcp-5c
Work Capacity Evaluation Form FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form ca-20
Attending Physicians Report FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
Form ca-16
Authorization for Examination and/or Treatment FECA Medical Report Forms, Claim for Compensation		 Form and Instruction
CA-1305.doc Instruction
CA-1303.doc version1.doc Instruction
CA-1090.doc Instruction
qcm Letter to doctor, no return to work.doc Instruction
qcm letter to doctor (no rtw and nurse assigned).doc Instruction
ca-17 Duty Status Report
ca-17.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf 		Form and Instruction
CA-7 Claim for Compensation
ca-7.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-7.pdf 		Form and Instruction
CA-17 Duty Status Report
ca-17.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf 		Form and Instruction
CA-1331 Authorization to doctor for audiologic and otologic eval
CA-1331 & CA-1087.doc 		Form and Instruction
CA-1332 Outline for Otologic Testing
CA-1332 outline for otologic testing.doc 		Form and Instruction
OWCP-5A Work Capacity Evaluation
OWCP-5a.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-5a.pdf 		Form and Instruction
owcp-5b Work Capacity Evaluation
OWCP-5b.pdf
www.dol.gov/esa/compliance/owcp/ca-5b.pdf 		Form and Instruction
owcp-5c Work Capacity Evaluation Form
OWCP-5c.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-5c.pdf 		Form and Instruction
ca-20 Attending Physicians Report
ca-20.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-20.pdf 		Form and Instruction
ca-16 Authorization for Examination and/or Treatment
ca-16.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction ca-17 http://www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf Yes No Fillable Printable
Form and Instruction CA-7 http://www.dol.gov/esa/regs/compliance/owcp/ca-7.pdf Yes No Fillable Printable
Form and Instruction CA-17 http://www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf Yes No Fillable Printable
Form and Instruction CA-1331 No   Paper Only
Instruction No   Paper Only
Instruction No   Paper Only
Instruction No   Paper Only
Form and Instruction CA-1332 No   Paper Only
Instruction No   Paper Only
Instruction No   Paper Only
Form and Instruction OWCP-5A http://www.dol.gov/esa/regs/compliance/owcp/ca-5a.pdf Yes Yes Fillable Fileable Signable
Form and Instruction owcp-5b http://www.dol.gov/esa/compliance/owcp/ca-5b.pdf Yes Yes Fillable Fileable Signable
Form and Instruction owcp-5c http://www.dol.gov/esa/regs/compliance/owcp/ca-5c.pdf Yes Yes Fillable Fileable Signable
Form and Instruction ca-20 http://www.dol.gov/esa/regs/compliance/owcp/ca-20.pdf Yes Yes Fillable Fileable Signable
Form and Instruction ca-16 No   Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 294,540 0 0 -7,945 0 302,485
Annual IC Time Burden (Hours) 30,493 0 0 -255 0 30,748
Annual IC Cost Burden (Dollars) 132,543 0 0 11,543 0 121,000

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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