Information Collection

FECA Medical Report Forms, Claim for Compensation

IC 13770 under ICR 201104-1240-001 · OMB 1240-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0046 can be found here:

Documents and Forms

Document Name Document Type
Form CA-7 FECA Medical Report Forms, Claim for Compensation Form and Instruction
CA-1305 final.rtf Instruction
CA-1090 Attendant Allowance final.rtf Instruction
CA-7 Claim for Compensation CA-7 - FINAL.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-17 Duty Status Report ca-17 - FINAL.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1331 Authorization to doctor for audiologic and otologic eval CA-1331 05-27 final.rtf Form and Instruction
CA-1332 Outline for Otologic Testing ca-1332 final.doc Form and Instruction
OWCP-5A Work Capacity Evaluation OWCP-5a - final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
owcp-5b Work Capacity Evaluation OWCP-5b - final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
owcp-5c Work Capacity Evaluation Form OWCP-5c - final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf Form and Instruction
ca-20 Attending Physicians Report ca-20 - final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
ca-16 Authorization for Examination and/or Treatment CA-16 - FINAL.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FECA Medical Report Forms, Claim for Compensation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.211 20 CFR 10.300 20 CFR 10.314 20 CFR 10.331 20 CFR 10.102

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-7	Claim for Compensation	CA-7 - FINAL.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-17	Duty Status Report	ca-17 - FINAL.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-1331	Authorization to doctor for audiologic and otologic evaluation	CA-1331 05-27 final.rtf		No		Paper Only
Instruction			CA-1305 final.rtf		No		Paper Only
Instruction			CA-1090 Attendant Allowance final.rtf		No		Paper Only
Form and Instruction	CA-1332	Outline for Otologic Testing	ca-1332 final.doc		No		Paper Only
Form and Instruction	OWCP-5A	Work Capacity Evaluation	OWCP-5a - final.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	owcp-5b	Work Capacity Evaluation	OWCP-5b - final.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	owcp-5c	Work Capacity Evaluation Form	OWCP-5c - final.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Yes	No	Fillable Printable
Form and Instruction	ca-20	Attending Physicians Report	ca-20 - final.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	ca-16	Authorization for Examination and/or Treatment	CA-16 - FINAL.pdf		No		Paper Only

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16826

Number of Respondents: 232,853	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	232,853	-61,687	294,540
Annual IC Time Burden (Hours)	21,212	-9,281	30,493
Annual IC Cost Burden (Dollars)	109,441	-23,102	132,543

Documents for IC

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.