Federal Employees' Compensation Act Medical Report Forms, Claim for Compensation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ca-16 Authorization for Examination and/or Treatment	Form and Instruction	Modified	Available
Form ca-20 Attending Physicians Report	Form and Instruction	Modified	Available
Form owcp-5c Work Capacity Evaluation Form, Musculoskeletal Conditions	Form and Instruction	Modified	Available
Form owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions	Form and Instruction	Modified	Available
Form OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Conditions	Form and Instruction	Modified	Available
Form CA-1332 Outline for Otologic Testing	Form and Instruction	Modified	Available
Form CA-1331,with CA-10 Authorization to Doctor for Audiologic and Otologic Evaluation and enclosure PWCP Hearing Loss Medical Requirements	Form and Instruction	Modified	Available
Form CA-17 Duty Status Report	Form and Instruction	Modified	Available
Form CA-7 Claim for Compensation	Form and Instruction	Modified	Available
BLS Average hourly and weekly earnings, production and nonsupervisory employees on private nonfarm payrolls omb1240-0046 2014.htm.docx	Supplementary Document	Uploaded 2014-06-26	Available
Occupational Employment and Wages Administrative Support-omb1240-0046 2014.docx	Supplementary Document	Uploaded 2014-06-26	Available
2014 opm salary table RUS_h, omb 1240-0046 2014.pdf	Supplementary Document	Uploaded 2014-06-26	Available
OWCP DFEC FECA omb 1240-0046 2014.docx	Supplementary Document	Uploaded 2014-06-26	Available
Supporting Statement 1240-0046 for 2014 revised final 10-27 mjs1.doc	Supporting Statement A	Uploaded 2014-10-27	Available
Privacty Act Systems-omb 1240-0046 2014.docx	Supplementary Document	Uploaded 2014-06-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Authorization for Examination and/or Treatment
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Attending Physicians Report
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation Form, Musculoskeletal Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation, Psychiatric/Psychological Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Outline for Otologic Testing
13770	FECA Medical Report Forms, Claim for Compensation	Instruction	Modified
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Authorization to Doctor for Audiologic and Otologic Evaluation and enclosure PWCP Hearing Loss Medical Requirements
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Duty Status Report
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Claim for Compensation

ICR Details

OMB Control No: 1240-0046	ICR Reference No: 201406-1240-002
Status: Historical Active	Previous ICR Reference No: 201204-1240-002
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: 01/16/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/31/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved	01/31/2015
Responses	282,353	0	232,853
Time Burden (Hours)	25,605	0	21,212
Cost Burden (Dollars)	110,118	0	109,441

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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 U S.C. 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:
	79 FR 38073	07/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 64836	10/31/2014
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
FECA Medical Report Forms, Claim for Compensation	owcp-5c, owcp-5b, CA-7, CA-17, CA-1331,with CA-1087 enclosed, CA-1332, OWCP-5a, ca-16, ca-20	Claim for Compensation ,   Duty Status Report ,   Authorization to Doctor for Audiologic and Otologic Evaluation and enclosure PWCP Hearing Loss Medical Requirements ,   Outline for Otologic Testing ,   Work Capacity Evaluation, Psychiatric/Psychological Conditions ,   Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions ,   Work Capacity Evaluation Form, Musculoskeletal Conditions ,   Attending Physicians Report ,   Authorization for Examination and/or Treatment

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ICR Summary of Burden

table that charts list 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	282,353	232,853	0	0	49,500	0
Annual Time Burden (Hours)	25,605	21,212	0	0	4,393	0
Annual Cost Burden (Dollars)	110,118	109,441	0	0	677	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 increased from 232,853 to 282,353, which is an adjustment of 49,500 responses. Accordingly, the burden hours increased from 21, 2012, to 25, 605, which is an adjustment of 4,393 burden hours. The burden costs have increased from $109,441 to $110,118, a difference of $677.

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Annual Cost to Federal Government: $1,015,828

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: 10/31/2014

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