Federal Employees Compensation Act Medical Report Forms, Claim for Compensation

Forms and Documents

Document Name	Status
Form CA-7 FECA Medical Report Forms, Claim for Compensation Form and Instruction	Modified
summary of revisions 1240-0046version final.doc Supplementary Document	2011-07-28
Office and Administrative Support Occupations.mht Supplementary Document	2011-04-20
national average hourly earnings of private production workforce.txt Supplementary Document	2011-04-20
rus_h.pdf Supplementary Document	2011-04-20
1215-0103 OMB Form 83-12.doc Supplementary Document	2008-07-17
1240-0046_SUPPORTING_STATEMENT_FINAL20110919.doc Supporting Statement A	2011-09-19
DOL_GOVT-1.doc Supplementary Document	2008-03-14
Compensation Act.doc Supplementary Document	2008-03-14

IC Document Collections

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

ICR Details

OMB Control No: 1240-0046	ICR Reference No: 201104-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-046
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Federal Employees Compensation Act Medical Report Forms, Claim for Compensation
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/31/2011
	Date Received in OIRA: 09/23/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	36 Months From Approved	10/31/2011
Responses	232,853	0	294,540
Time Burden (Hours)	21,212	0	30,493
Cost Burden (Dollars)	109,441	0	132,543

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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:
	76 FR 28818	05/18/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 59163	09/23/2011
Did the Agency receive public comments on this ICR? No

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

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	Claim for Compensation ,   Duty Status Report ,   Authorization to doctor for audiologic and otologic evaluation ,   Outline for Otologic Testing ,   Work Capacity Evaluation ,   Work Capacity Evaluation ,   Work Capacity Evaluation Form ,   Attending Physicians Report ,   Authorization for Examination and/or Treatment

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ICR Summary 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	232,853	294,540	0	0	-61,687	0
Annual Time Burden (Hours)	21,212	30,493	0	0	-9,281	0
Annual Cost Burden (Dollars)	109,441	132,543	0	0	-23,102	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 294,540 to 232,853, which is an adjustment of 61,687 responses. Accordingly, the burden hours decreased from 30,493 to 21,212, which is an adjustment of 9,281 burden hours. Consequently, the drop in both respondents and burden hours has decreased cost from $132,543 to $109,441, a reduction of $23,102. In addition to the removal of forms CA-1303 and the qcm letters from this collection, we attribute the reduction in part due to the decrease in the number of claims as a result of a Presidential initiative for the Safety, Health and Return to Employment (SHARE) initiative, which was launched in 2004 with the purpose of reducing occupational injuries, illnesses and fatalities within the Federal government.

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Annual Cost to Federal Government: $718,125

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 09/23/2011

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