Summary of Revisions

SUMMARY OF REVISIONS

OMB 1240-0046

EXPIRATION DATE OF SEPTEMBER 30, 2011

1. CA-7

Page 1

Section 1a,

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Section 7, bottom of page, added form number and revision date, i.e., CA-7, (Rev. 05-11)

Page 2

• Section 15, bottom of page, added form number/page number and revision date, i.e., CA-7, page 2 (Rev. 05-11)

Page 3

• Revised references in CFR under 4^th bullet, Collection of information….. to 20 C.F.R. 102 and 20 C.F. R. 103 versus 20 C. F. R. 106.

• Added form number, page and revision date, i.e., CA-7, page 3 (Rev. 05-11)

Page 4

• Added form number, page and revision date, i.e., CA-7, page 4 (Rev. 05-11)

2. CA-16

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Part A, #1. Deleted comma after Medical.

• Part A, #2. Added SSN to Employee's Identification (last, first, middle name, SSN)

• Part A, #6. Revised second sentence as follows, .....in item A, and to the condition indicated in either 1 or 2, item B.

• Part A. 6. B. 2. Added space between “employment” and “pending” in 4th line.

Deleted period between "provide" and "necessary"

• Under Public Burden Statement, 4th line, capitalized the "l" in labor

• Revised page/form number as Form CA-16 (Rev. 05-11)

• Added statement, “any duplication or reproduction of this form, to include via electronic means, is prohibited without the express written consent by OWCP.”

• Add statement at bottom of page that Previous Revisions Obsolete

Page 2

• Bottom of page under Medical Billing. Delete AMA OP 407/408/409 reference Revised second sentence as follows: “Physician services must be itemized by Current Procedural Terminology (CPT) using current CPT-4 coding schema or the UB-04 and the coding schemas acceptable on this form. “

• Revised page/form number as Form CA-16, page 2 (Rev. 05-11)

Page 3

• Under Selection of Physician, second bullet, line 2. Delete reference to AMA OP 407/408/409.

• Third bullet.

Replace this A physician who is debarred from the FECA program as provided at 20 CFR 10.450-457 may not be authorized to examine or treat an injured Federal employee.

With this A physician who is excluded from the FECA program as provided at 20 CFR 10.815-826 may not be authorized to examine or treat an injured Federal employee.

• Fourth bullet.

Replace this Generally, 25 miles from the place of injury, employing agency, or the employee's home is a reasonable distance to travel for medical care; however, other pertinent factors must also be considered.

With this Generally, a roundtrip distance of up to 100 miles from the place of injury, employing agency, or the employee's home is a reasonable distance to travel for medical care; however, other pertinent factors must also be considered.

• Fifth bullet

Replace this Form CA-16 is valid for up to sixty days from date of issuance, and may be terminated earlier upon written notice from OWCP to the provider. It should not be used to authorize a change of physicians after the initial choice is exercised by the employee.

With this Form CA-16 is valid for up to sixty days from date of injury, and may be terminated earlier upon written notice from OWCP to the provider. It should not be used to authorize a change of physicians after the initial choice is exercised by the employee.

                   

• Federal Medical Facilities, first sentence. Replaced first sentence with “ U. S. Medical Facilities include Army, Navy, Air Force or the VA versus U. S. medical facilities include Public Health Service…….or VA hospitals.

• Third sentence. Replaced 20 CFR 10.400, with 20 CFR 10.300

• Definition of Injury (Add) as last sentence the following: “Simple exposure to a workplace hazard, such as an infectious agent, does not constitute a work place injury, entitling an employee to medical treatment under FECA”.

• 9^th Bullet

Part A shall be completed in full by the authorizing official. The authorization is not valid unless the name and address of the physician or hospital is entered in Item 1 and the signature of the authorizing official appears in Item B. Check B1 or B2 or Item 6, whichever is appropriate.

Delete Red:

In care of illness or disease, only Box B2 may be checked.

• Additional Information. Revised as “See 20 CFR and/or Publication CA-810, Injury Compensation for Federal Employees' vs. Chapter 810.....Federal Personnel Manual (FPM).

• Revised page/form number/revision date as Form CA-16, page 3 (Rev. 05-11)

Page 4

• Top of Page, Change heading to “Instructions for Authorized Physician/Medical Facility” vs. Information for Physician.

• Your Authorization. Third line, replaced "issuance" with "injury"; fourth sentence, replaced 20 CFR 10.450-457 with, 20 CFR 10.815-826

• Billing for Services, second line, delete reference to AMA OP 407/408/409.

Delete sentences the remaining sentences, “Each procedure……A copy of this form….treatment is sought” and replace with the following bullets.

• OWCP requires that when services are provided by a private physician, charges be itemized using the AMA standard Health Insurance Claim Form, HCFA-1500/OWCP-1500. The form should contain appropriate International Classification of Disease (ICD-9) coding schemas in Block-21, and related correctly to the Diagnosis Pointers referenced in Block 24E. The form should also identify services rendered using the Current Procedural Terminology (CPT-4), and HealthCare Common Procedure Codes (HCPC) schemas.

• OWCP requires that when services are performed in an emergency situation, and in an Acute Care Facility for emergency surgery or care, a copy of the OWCP Uniformed Billing Form (UB-04-1450), should be supplied together with the submitted Form CA-16. The form should contain the appropriate International Classification of Diseases (ICD-9) coding schemas in Blocks 66-70, and reference any surgical procedures performed in the facility in Blocks 74a-74e using the International Classification of Disease ICD-9 Surgical Procedure Codes. The UB-04 should be itemized in Block #42 in a summarization listing all ancillary services performed during the stay, and each service; (radiology, Labs, pharmacy, supplies etc;) should be referenced using Revenue Center Codes (RCC).

• Tax Identification. Replace the sentences, the provider’s TAX Identification…..which is used consistently on OWCP claims with the following.

• The Provider/Facility Tax Identification Number (TIN) is an important identifier in the OWCP system. To ensure accurate processing and to reduce inaccuracy of payment, the provider billing on an OWCP-1500 billing form should reference the TIN (Employer Identification Number or SSN in Block #25, and indicate this identifier on all submitted reports and billings submitted consistently. The Tax Identification Number for Facilities billing on the UB-04 Billing form, should reference their Federal Tax Identification number in Block #5.

• Additional Information, after sentence, contact the OWCP… Part A. Add the following, "Refer to Information for Medical Providers at http://www.dol.gov/owcp/dfec/index.htm

• Revised page/form number as Form CA-16, page 4 (Rev. 05-11)

Page 5

• Replaced current Privacy Act Statement with the following:

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are here by notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S .Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Note: This notice applies to all forms requesting information that you might receive

from the Office in connection with the processing and adjudication of the claim you

filed under the FECA.

3. CA-17

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Bottom of page, added form and revision dates as CA-17 (Rev. 05-11)

Page 2

• Removed Public Burden Statement and placed with Privacy Act Statement on page 3

• Added form/page/revision as CA-17, page 2 (Rev. 05-11)

Page 3

• Added a Privacy Act Statement. Used format noted in CA-16 above.

• Revised Public Burden Statement as follows:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not send the completed form to this office.

• Add form/page/rev at bottom of page, CA-17, page 3 (Rev. 05-11)

4. CA-20

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Items 16, 17, 18. Applied consistency in punctuation. Note: for example some areas in current form have periods, while others have commas after "mo'

• Added form and revision date to bottom of form, CA-20 (Rev. 05-11)

Page 2

• Move Instructions to Physician Report (CA-20), ... (items 1, 2, and 3) with address info to top of page 2.

• Follow next with caption, “Important:” A medical report........

• Third bullet under Important”, delete “a” in 1500

• Below this, add two paragraphs from page 3, Compensation for wage loss......to the employment”. “For payment of a ……Permanent Impairment”.

• 2d sentence. add an "and" here and delete the comma after CA-20 .

• 3^rd sentence, delete “and print the OWCP district office address on the reverse.

• Delete Public Burden Statement and place on page 3 along with the Privacy Act Statement.

• Add Form, Page, Rev # as CA-20, page 2 (Rev. 05-11)

Page 3

• Move two paragraphs, Compensation.....for payment of... to page 2 as noted above and change reference to (20 C.F.R. 10.404)

• Revise page 3 as follows: Add the word Statement after Privacy Act

• Add Public Burden Statement after Privacy Act as follows:

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to this office.

• Add Form/Page/Rev as follows: CA-20 Page 3 (Rev. 05-11)

5. OWCP 5a

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Item 7. Added Area Code to the Telephone Number.

• Delete the sentence, “The information…..5 USC 8101 et.seq and the Public Burden Statement.”

• Add Form and revision to bottom of page, add OWCP 5a (Rev. 05-11).

Page 2

• Added the following Privacy/Public Burden Statements

Privacy Act Statement

The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101 et seq.), authorizes collection of this information. The purpose of this form is to obtain the claimant’s specific work tolerance limitation where the accepted condition is psychiatric or psychological in nature. Completion of this form is voluntary (5 U.S.C. 8101 et seq), however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.

• Add page/form/revision to bottom of page, .OWCP 5a, page 2 (Rev. 05-11)

6. OWCP 5b

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Item 7. Added Area Code to the Telephone Number

• Deleted and revised Information after item 9, i.e., The information…to obtain or retain a benefit (5 USC 8101 et.seq.) and the Public Burden Statement (revised) and place on same page as Privacy Act on page 2)

• Added form and revision date at bottom of page OWCP 5b (Rev. 05-11)

Page 2

• Added the word, “Statement” after Privacy Act

• Replaced existing Privacy Act Statement with same as OWCP 5a except noted in line 4 that this form pertains to cardiovascular/pulmonary conditions.

• Replaced existing Public Burden Statement with the same as OWCP 5a above

• Added form, page and revision date at bottom of page .OWCP 5b Page 2 (Rev. 05-11)

7. OWCP 5c

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• item 5, add Area Code in the Telephone Number

• Delete and revised Information after item 7, i.e., (The information…to obtain or retain a benefit (5 USC 8101 et.seq.) and the Public Burden Statement (revised) and place on same page as Privacy Act on page 2)

• Revise form and revision date at bottom of page as OWCP 5c (Rev. 05-11)

Page 2

• Added the word, “Statement” after Privacy Act

• Replaced existing Privacy Act Statement with same as OWCP 5a and 5b except noted in line 4 that this form pertains to cardiovascular/pulmonary conditions.

• Replaced existing Public Burden Statement with the same as OWCP 5a/5b above

• Added form, page and revision date at bottom of page .OWCP 5c Page 2 (Rev. 05-11)

8. CA-1305

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX

• Last paragraph, first line, delete “a” in 1500; add HCFA 1500 after OWCP 1500. .

• Added form and revision date at bottom of page, CA-1305 (Rev. 05-11)

Page 2

• Last paragraph, third line, delete “a” in 1500.

• In the enclosure, deleted “a” in 1500, add, HCFA 1500 after OWCP 1500

• Add form, page, and revision date at bottom of page, CA-1305, page 2 (Rev. 05-11)

• Removed current OMB No and placed on first page as described above.

Page 3

• Renamed Notice to Recipient as Public Burden Statement and placed underneath Privacy Act (with revisions) as follows

Privacy Act Statement

The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101. et seq.), authorizes collection of this information. The information will be used in cases involving eye injury to determine the extent of loss of vision in complicated eye injury cases. Completion of this form is voluntary, however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number.

Public reporting burden for this collection of information is estimated at 20 minutes to complete the collection of this information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101. et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.

• Added form, page, and revision date at bottom of page, CA-1305, page 3 (Rev. 05-11)

9. CA-1090

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX. Moved OMB No/Expiration Date to Upper Right Corner of Letter from bottom page

• Second paragraph, deleted first sentence “If services are approved, payment for such services is limited to $1500 per month by regulation Payment”

• Added form and revision date at bottom of page, CA-1090 (Rev. 05-11)

• Removed OMB No at bottom of page and placed as noted above.

Pages 2 through 4.

• Added form, page, and revision date at bottom of page, i.e., CA-1090 Page 2 (Rev. 05-11)

Page 5

• Replaced previous Privacy Act/Public Burden Statement and revised as follows:

Privacy Act Statement

The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101 et seq.), authorizes collection of this information. The purpose of this form is to determine authorization and payment for services of an attendant where it is medically documented that an injured worker requires assistance to care for personal needs such as bathing, dressing, eating, etc. Completion of this form is voluntary (5 U.S.C. 8101 et seq), however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.

• Added form, page, and revision date at bottom of page, i.e., CA-1090 Page 5 (Rev. 05-11)

10. CA-1331/CA-1087

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX Moved OMB No/Expiration Date to Upper Right Corner of Letter from bottom of page

• Sixth paragraph, revised second sentence with the following: The billing form must contain the provider's tax identification number (Social Security Number or EIN) in block 25 and the signature in Block 31. Note: This begins page 2.

• Added form and revision date at bottom of page, i.e., CA-1331(Rev. 05-11)

• Removed OMB No from bottom of page and placed as noted above.

Page 2

• Replaced current Privacy Act/Public Burden Statement and revised as follows

Privacy Act Statement

The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101 et seq.), authorizes collection of this information. The information will be used in conjunction with the Form CA-1332 to refer a claimant for complete audiologic and otologic examination when a claim for hearing loss has been filed. Completion of this form is voluntary, however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.

• Added form, page, and revision date at bottom of page, i.e., CA-1331, page 3 (Rev. 05-11) PREVIOUSLY PAGE 2

Pages 4 and 5 (CA-1087 Enclosure)

• Added Enclosure, page, and revision numbers, i.e., CA-1087 (Rev. 05-11) and CA-1087, page 2 (Rev,. 05-11)

Page 6

• Revised and added Privacy Act and Public Burden Statements as noted above.

11. CA-1332

Page 1

• In the OMB No block, changed current expiration date of 9/30/2011 to XX-XX-XXXX.

• 1E, first line, correct spelling of sysmetic to systemic

• Added form and revision numbers at bottom of page, , i.e., CA-1332 (Rev. 05-11)

Page 2

• Bottom of page, added “date” after physician signature

• Added form, page and revision numbers at bottom of page, i.e., CA-1332, page 2 (Rev. 05-11)

Pages 3 and 4

• Added form, page, and revision numbers, i.e., CA-1332, page 3 (Rev. 05-11) and CA-1332, page 4 (Rev,. 05-11)

Page 5

Added Privacy Act and Public Burden Statements as follows;

Privacy Act Statement

The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101 et seq.), authorizes collection of this information. The information will be 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. Completion of this form is voluntary, however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”

Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to vary from 15 to 45 minutes per response with an average of 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.

• Added form, page, and revision numbers, i.e., CA-1332, page 3 (Rev. 05-11) and CA-1332, page 5 (Rev,. 05-11)

FOR ALL FORMS/LETTERS THE FOLLOWING ACCOMMODATION STATEMENTS WERE ADDED

AS INSTRUCTIONS/NOTES, AND OR PRIVACY ACT/PUBLIC BURDEN PAGES(CA-7, CA-16, CA-17, CA-20, and the OWCP-5s)

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from DFEC in the form of communication assistance, accommodation and modification to aid you in the FECA claims process.  For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability.  Please contact our office or your claims examiner to ask about this assistance. 

*Note: On OWCP-5s, last sentence above, reads, Please contact our office or the claims examiner to ask about this assistance.

FOR CORRESPONDENCE LETTERS (AS FOOTNOTES) (CA-1090, CA-1305, CA-1331, CA-1332)

If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims examiner for information about the kinds of help available such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications. 

Note: The above was also added to the second instruction page of the CA-16

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