Supporting Statement for 1215-0103 (Various CA Forms) July 15 2008

Supporting Statement

FECA Medical Report Forms, Claim for Compensation

OMB No. 1215-0103

A. Justification.

1. The Office of Workers' Compensation Programs (OWCP) administers the Federal Employees' Compensation Act (FECA), 5 USC 8101 et. seq. The statute provides for the payment of benefits for wage loss and/or for permanent impairment to a scheduled member, arising out of a work related injury or disease. The Act outlines the elements of pay which are to be included in an individual's pay rate, and sets forth various other criteria for determining eligibility to and the amount of benefits, including: augmentation of basic compensation for individuals with qualifying dependents; a requirement to report any earnings during a period that compensation is claimed; a prohibition against concurrent receipt of FECA benefits and benefits from OPM or certain VA benefits; a mandate that money collected from a liable third party found responsible for the injury for which compensation has been paid be applied to benefits paid or payable. The CA-7 (Claim for Compensation requests information, allowing OWCP to fulfill its statutory requirements, for the period of compensation claimed (e.g., the pay rate, dependents, earnings, dual benefits and third party information).

http://www.access.gpo.gov/uscode/title5/partiii_subpartg_chapter81_subchapteri_.html

http://www.access.gpo.gov/nara/cfr/waisidx_07/20cfr10_07.html

The other forms in this clearance collect medical information necessary to determine entitlement to benefits under the FECA. Before compensation may be paid, the case file must contain medical evidence showing that the claimant's disability is causally related to the claimant's federal employment. As a particular claim ages, there is a continuing need for updated information to support continuing benefits. The various forms included in this ICR and the purpose of each are listed below:

CA-7 -- The CA-7 is used to claim compensation (20 CFR 10.102). The front page is completed by the claimant. On the back page, the employing agency verifies the accuracy of the claimant's statements and provides relevant information from agency records. If a previous CA-7 claim has been made, only certain sections of the form are completed for subsequent claims.

 

In the vast majority of cases, compensation is claimed while a claimant continues to be employed by the Federal Government. In those cases, the CA-7 is completed by a Federal employee and their supervisor, therefore not affecting the public. The CA-7 is required of a member of the public on rare occasions, such as when compensation is claimed after the claimant's Federal

employment has been terminated. It is estimated that no more than 400 of these forms are required of members of the public through the course of a year. This request for clearance by OMB only pertains to a small percentage of the overall use of the

CA-7.

CA-16 -- Part of the form is completed by the physician who first treats the injured employee. The form is in two parts; Part A is completed by the Federal employer (20 CFR 10.211, 10.300 and 10.331).

CA-17 -- Part b of this form is completed by the physician. The form is used on a periodic basis, so that an assessment of the employee's condition and ability to perform work can be monitored (20 CFR 10.506).

CA-20 (Attached to the CA-7)-- The claimant uses this form to obtain medical documentation from the attending physician to support disability for the period claimed on the CA-7 (20 CFR 10.102).

CA-1090 -- Attendant Allowance is used to obtain information to determine if a claimant is entitled to the services of an attendant (20 CFR 10.314). This form has been revised so that it is now addressed to the claimant, asking the claimant for information and to arrange for information from their physician. This letter was previously addressed to the physician. The burden was increased from 5 to 10 minutes based upon the additional information asked of the claimant.

CA-1303 -- Used to advise an injured employee’s physician that OWCP needs an evaluation of permanent impairment related to an accepted injury. The employee may be entitled to a schedule award if they have suffered permanent loss or loss of use of a scheduled member (5 USC 8107 and 20 CFR 10.404). Medical evidence describing any permanent impairment, in accordance with the current edition of the AMA Guides, is needed to determine entitlement. There are 9 different versions of this form. Each addresses a different kind of injury.

CA-1305 -- Used only in cases involving eye injury to determine the extent of claimant's loss of vision. May be used if the report is being requested from the claimant's current attending physician, or from a physician to whom the claimant is being referred for examination. While this form letter is used very infrequently, it helps claims examiners develop a very difficult issue and is therefore remaining in inventory.

CA-1087, CA-1331 -- Used in conjunction with the Form CA-1331 to refer a claimant for complete audiologic and otologic examination when a claim for hearing loss has been filed.

CA-1332 -- Used to obtain a complete report of audiologic and otologic examination. Use of the CA-1332 outline is optional, but when used, it should simplify the process of developing the report for the respondent and result in an improved report.

QCM letters --There are 2 versions of this letter, one to use when a projected return to work date is extended by the employee’s physician and one for use when no return to work date is provided. These letters are used to obtain a treatment plan from the attending physician and a projected date for return to light or full duty. It advises the treating physician of the Office’s goal of returning the claimant to work, and that the Office will pay for treatment of the work-related condition.

OWCP-5a -- Used to obtain the claimant's specific work tolerance limitations where the accepted condition is psychiatric or psychological in nature. It may also be used as an attachment to any original or form letter seeking work limitations.

OWCP-5b -- Used to obtain claimant's work tolerance limitations where the accepted condition is cardiovascular or pulmonary in nature. It may also be used as an attachment to an original or form letter seeking work limitations.

OWCP-5c -- Used to obtain the claimant's work tolerance limitations when the accepted condition is musculoskeletal in nature. It may also be attached to any original or form letter which seeks work limitations.

The appropriate sections of the FECA and the implementing Regulations are attached. Authority to collect Social Security Numbers is provided by P.L. 106-113. http://www.socialsecurity.gov/policy/docs/ssb/v58n1/v58n1p57.pdf

2. The information collected by these forms is used by claims examiners for OWCP to determine eligibility for and the computation of benefits. The claim forms, with the medical evidence, are used to determine whether or not the claimant is entitled to compensation for disability for work or permanent

impairment of a scheduled member; the appropriate period, rate of pay, compensation rate, any concurrent employment or dual benefits, and third party credit. The OWCP-5 forms are also used by rehabilitation specialists and nurses to assist partially disabled employees to return to suitable employment. Without the requested information, an eligible beneficiary could be denied benefits, or benefits could be authorized at an incorrect rate, resulting in an underpayment or overpayment of compensation.

3. In accordance with the Government Paperwork Elimination Act (GPEA), the Division of Federal Employees’ Compensation seeks to allow individuals and entities that deal with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate. As a result, numerous forms are now available on the internet and some can be submitted electronically. Currently, Forms CA-20, OWCP – 5-a, OWCP 5-b and OWCP 5-c are available for electronic submission. These forms can be found on the Department of Labor’s website at the following internet addresses:

CA-20 http://www.dol.gov/esa/regs/compliance/owcp/ca-20.pdf

OWCP 5a http://www.dol.gov/esa/regs/compliance/owcp/OWCP-5a.pdf

OWCP 5b http://www.dol.gov/esa/regs/compliance/owcp/OWCP-5b.pdf

OWCP 5c http://www.dol.gov/esa/regs/compliance/owcp/forms.htm

Links to all of these forms are available at http://www.dol.gov/esa/regs/compliance/owcp/forms.htm.

Citizens are made aware of the electronic filing options through the Department of Labor’s website. In addition, employing agencies and claimants are notified of this option during training sessions given by the OWCP.

Form CA-16 is initiated solely by the employing agency and is not available on line for download or electronic submission as it is not a public use form and is available to the employing Agency for purchase only via the Government Printing Office. Forms CA-7, and CA-17 are available on line and can be downloaded, printed and are fillable, however, the forms are not available for electronic submission as they are initiated by the employing agency, require multiple signatures and are not primarily for the general public. Forms CA-1090, CA-1303, CA-1305, CA-1331, CA-1332(CA-1087) and QCM letters are all generated solely by the government agency (OWCP) and not the general public.

4. The information requested on these forms is not duplicative of any information available elsewhere. The claimant, their employer, and their physician are the only sources of the required information. The forms have been streamlined over the years to obtain the necessary medical information while imposing the minimum burden on the respondent. In addition, the information is not collected unless the information is necessary for the adjudication of the case.

5. This information collection does not have a significant economic impact on a substantial number of small entities.

6. If this information was not collected, or was collected less frequently, OWCP would be unable to properly provide disability benefits to injured Federal employees. If benefits were paid in the absence of full information, there would be numerous incorrect payments, creating overpayments, and depriving claimants of benefits to which they are entitled.

7. Special circumstances which apply to this ICR are as follows:

a. Medical information necessary to determine entitlement to benefits is requested on an as-needed basis. Therefore, respondents often are required to provide information more frequently than quarterly. The need for updating this information is constant. As the medical status of a claimant changes over time, updated medical information must be requested to determine continuing entitlement to compensation.

For example, a claimant who has been paid compensation for specific periods may file a claim for a subsequent period of disability. In order to determine if the claimant is entitled to compensation for that period, the claimant must submit medical documentation pertaining to the period. The OWCP reviews this medical information and uses it to make a decision as to whether or not the claimant is entitled to compensation for the period claimed.

b. Oftentimes medical information is needed from the respondent in less than thirty days. For instance, medical information is needed in order to adjudicate a claim and pay compensation. If the claimant is off work and without income, the prompt submission of the medical needed to support the claim will reduce the financial hardship of the respondent. Also, medical information is needed quickly so that medical treatment and surgeries can be timely authorized and reduce the recovery time of the respondent.

There are no other special circumstances for the collection of this information.

8. A Federal Register Notice inviting comment was published on April 16, 2008. No comments were received. The Medical staff of OWCP works closely with the medical community. Also, claims, rehabilitation staff and contract nurses work with treating physicians towards returning injured workers to work. As a result ongoing feedback is provided from the medical community regarding the required OWCP forms.

9. No payment or gift is provided to respondents, other than payments to contractors.

10. The information collected by these forms is maintained in FECA claim files, which are fully protected under the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1. The Privacy Act Statement has been added to the various forms that are associated with this information collection. http://www.usdoj.gov/oip/privstat.htm and http://www.dol.gov/sol/privacy/dol-govt-1.htm

11. No questions regarding sexual behavior, religious beliefs, etc. are asked. The medical information collected would be considered sensitive, but is essential for proper evaluation of entitlement to benefits. The notice of injury, completed by a claimant, for FECA benefits includes an authorization for release of medical records. The form explains how the records are used and that they are protected by the Privacy Act. The CA-7 does not ask questions of a sensitive nature.

12. The attached burden distribution matrix form shows a comparison of the current burden hour’s inventory and the proposed new hours. Burden hour estimates have been derived from actual respondent usage of these forms. Each estimate represents an average amount of time it takes one respondent to complete one form.

Burden Hours:

FORMS #	Estimated Annual Responses	Average Response Time (hours)	Estimated Annual Burden Hours
CA-7	400	13	87
MEDICAL REPORT FORMS
CA-16	124800	5	10400
CA-17	57600	5	4800
CA-20	76800	5	6400
CA-1332	480	30	240
CA-1090	300	10	50
CA-1303	3200	20	1067
CA-1305	10	20	3
CA-1331 / CA-1087*	250	5	21
QCM - Letters	1500	5	125
OWCP-5a	7200	15	1800
OWCP-5b	5000	15	1250
OWCP-5c	17000	15	4250
TOTAL	294540		30493

*Responses and hours associated with Form CA-1087 are included in the estimates for the Form CA-1331. The Form CA-1087 will be attached to the Form CA-1331.

Burden Hour Costs:

Medical report forms are generally completed by administrative support staff based on physician's notes. The cost to the respondent on the completion of the medical forms is estimated based upon the mean wage rate of $14.60 (BLS, Occupational Employment and Wages Occupational Code 43-0000 for Office and Administrative Support Occupations, May 2006.) The May 2007 information is not yet available from BLS. The total respondent time for the medical report forms is 30,406 hours, for a cost of $443,928. http://www.bls.gov/oes/current/oes430000.htm

The burden hours for the CA-7 Form have remained the same. The Office has received fewer wage loss CA-7 forms; however, because there was an increase in the number of CA-7 forms received for Schedule Awards, the number of CA-7 received offset each other resulting in no gain in burden hours. The cost to the respondent for completing Form CA-7 is determined by using the National Average Hourly Earnings of Private Production Workers – not seasonally adjusted as computed by BLS of $17.43(p) per hour. The respondent time for the CA-7 is 87 hours, for a cost of

$1,516.

http://data.bls.gov/cgi-bin/surveymost?ce

The total respondent cost: $443,928 + $1,516 = $445,444.

As medical facilities are already required to keep medical records, no additional record keeping time is included.

13. Because the medical information requested is kept as a usual and customary business practice, the only operation and maintenance cost associated with these forms is for mailing. A total of 294,140 responses at $.42 postage + $.03 envelope = $.45 per response (postage and envelope) = $ 132,363. Also, the only cost for submission of the CA-7 Form is the cost of mailing at $.45. A total of 400 responses at $.45 = $180.00. $132,363 + 180.00 = $132,543.

14. Federal Cost Estimate:

Review Costs: The average hourly wage for the reviewer is that of a GS-11/4, $28.72 per hour (Federal Salary Table for Rest of US, 2008). https://www.opm.gov/oca/08tables/pdf/rus_h.pdf

Time Total

Form to Review Respondents Cost

CA-7 13 min. 400 $2,499

CA-16 5 min. 124,800 $298,688

CA-17 5 min. 57,600 $137,856

CA-20 5 min. 76,800 $183,808

CA-1090 10 min. 300 $1,551

CA-1303 20 min. 3,200 $30,644

CA-1305 20 min. 10 $86

CA-1331 5 min. 250 $603

CA-1332 30 min. 480 $6,893

CA-1087 30 min. 250 $3,590

(Cost Only)

QCM Ltrs 5 min. 1,500 $3,590

OWCP-5a 15 min. 7,200 $51,696

OWCP-5b 15 min. 5,000 $35,900

OWCP-5c 15 min. 17,000 $122,060

Total Review Cost $879,464

Postage (most of these forms are enclosures or are hand carried to the claimant by the employer). Therefore, approximately only 1000 are mailed each year separately 1000 x $.45 = 450.00.

$879,464 + 450.00 mailing costs = Total Federal Cost: $879,914

15. 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.

16. Data collected with these forms will not be published.

17. DOL/ESA is not seeking an exemption to display the expiration date on the CA forms.

18. There are no exceptions to certification.

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