FECA Medical Report Forms, Claim for Compensation

Federal Employees Compensation Act Medical Report Forms, Claim for Compensation

OMB: 1240-0046

IC ID: 13770

Information Collection (IC) Details

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FECA Medical Report Forms, Claim for Compensation
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 10.211 20 CFR 10.300 20 CFR 10.314 20 CFR 10.331 20 CFR 10.102

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
Form and Instruction CA-7 ECOMP Claim for Compensation CA-7 (claimant portion)-ECOMP.docx https://www.ecomp.dol.gov/ Yes Yes Fillable Fileable Signable

Workforce Management Labor Rights Management

DOL/GOVT-1  67 FR 16826

232,853 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 232,853 0 0 0 0 232,853
Annual IC Time Burden (Hours) 21,212 0 0 0 0 21,212
Annual IC Cost Burden (Dollars) 109,441 0 0 0 0 109,441

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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