Information Collection

FECA Medical Report Forms, Claim for Compensation

IC 13770 under ICR 201602-1240-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 revised 8-2014 mjs.rtf Instruction
CA-1090 Attendant Allowance revised 8-2014 mjs.rtf Instruction
CA-7 Claim for Compensation ca-7_working_text_updates final mjs.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-17 Duty Status Report ca-17 final 9-2014 mjs.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-1331,with CA-10 Authorization to Doctor for Audiologic and Otologic Eval CA-1331 8-2014 mjs revised.rtf Form and Instruction
CA-1332 Outline for Otologic Testing ca-1332 revised 8-2014 mjs.doc Form and Instruction
OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Cond OWCP-5a - final.pdf 8-2014 mjs.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Condi OWCP-5b_working final.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
owcp-5c Work Capacity Evaluation Form, Musculoskeletal Condition OWCP-5c_working final mjs.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf Form and Instruction
ca-20 Attending Physicians Report ca-20 final 8-2014 mjs.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
ca-16 Authorization for Examination and/or Treatment CA-16 currently approved version expiring 2018 with ICD changes.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 10.300 20 CFR 10.331 20 CFR 10.102 20 CFR 10.211 20 CFR 10.314 20 CFR 10.506

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_working_text_updates final mjs.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 9-2014 mjs.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-1331,with CA-1087 enclosed	Authorization to Doctor for Audiologic and Otologic Evaluation and enclosure PWCP Hearing Loss Medical Requirements	CA-1331 8-2014 mjs revised.rtf		No		Paper Only
Instruction			CA-1305 final revised 8-2014 mjs.rtf		No		Paper Only
Instruction			CA-1090 Attendant Allowance revised 8-2014 mjs.rtf		No		Paper Only
Form and Instruction	CA-1332	Outline for Otologic Testing	ca-1332 revised 8-2014 mjs.doc		No		Paper Only
Form and Instruction	OWCP-5a	Work Capacity Evaluation, Psychiatric/Psychological Conditions	OWCP-5a - final.pdf 8-2014 mjs.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	owcp-5b	Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions	OWCP-5b_working 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, Musculoskeletal Conditions	OWCP-5c_working final mjs.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 8-2014 mjs.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 currently approved version expiring 2018 with ICD changes.pdf		No		Paper Only

Federal Enterprise Architecture Business Reference Module

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: 282,353	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Previously Approved
Annual Number of Responses for this IC	282,353	282,353
Annual IC Time Burden (Hours)	25,605	25,605
Annual IC Cost Burden (Dollars)	110,118	110,118

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.