FECA Medical Report Forms, Claim for Compensation

FECA Medical Report Forms, Claim for Compensation

OMB: 1240-0046

IC ID: 13770

Documents and Forms
Document Name
Document Type
Form and Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

FECA Medical Report Forms, Claim for Compensation
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction ca-17 Duty Status Report ca-17.pdf http://www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf Yes No Fillable Printable
Form and Instruction CA-7 Claim for Compensation ca-7.pdf http://www.dol.gov/esa/regs/compliance/owcp/ca-7.pdf Yes No Fillable Printable
Form and Instruction CA-17 Duty Status Report ca-17.pdf http://www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf Yes No Fillable Printable
Form and Instruction CA-1331 Authorization to doctor for audiologic and otologic evaluation CA-1331 & CA-1087.doc No   Paper Only
Instruction CA-1305.doc No   Paper Only
Instruction CA-1303.doc version1.doc No   Paper Only
Instruction CA-1090.doc No   Paper Only
Form and Instruction CA-1332 Outline for Otologic Testing CA-1332 outline for otologic testing.doc No   Paper Only
Instruction qcm Letter to doctor, no return to work.doc No   Paper Only
Instruction qcm letter to doctor (no rtw and nurse assigned).doc No   Paper Only
Form and Instruction OWCP-5A Work Capacity Evaluation OWCP-5a.pdf http://www.dol.gov/esa/regs/compliance/owcp/ca-5a.pdf Yes Yes Fillable Fileable Signable
Form and Instruction owcp-5b Work Capacity Evaluation OWCP-5b.pdf http://www.dol.gov/esa/compliance/owcp/ca-5b.pdf Yes Yes Fillable Fileable Signable
Form and Instruction owcp-5c Work Capacity Evaluation Form OWCP-5c.pdf http://www.dol.gov/esa/regs/compliance/owcp/ca-5c.pdf Yes Yes Fillable Fileable Signable
Form and Instruction ca-20 Attending Physicians Report ca-20.pdf http://www.dol.gov/esa/regs/compliance/owcp/ca-20.pdf Yes Yes Fillable Fileable Signable
Form and Instruction ca-16 Authorization for Examination and/or Treatment ca-16.pdf No   Paper Only

Workforce Management Labor Rights Management

DOL/GOVT-1 

294,540 0
   
Individuals or Households
 
   0 %

  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

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