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 10.300 20 CFR 10.331 20 CFR 10.102 20 CFR 10.211 20 CFR 10.314 20 CFR 10.506

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

Workforce Management Labor Rights Management

DOL/GOVT-1  67 FR 16826

282,353 0
   
Individuals or Households
 
   25 %

  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 282,353 0 0 0 0 282,353
Annual IC Time Burden (Hours) 25,605 0 0 0 0 25,605
Annual IC Cost Burden (Dollars) 110,118 0 0 0 0 110,118

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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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