Federal Employees' Compensation Act Medical Reports and Compensation Claims

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-1331 with CA-10 Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments	Form and Instruction	Modified	Available
Form CA-1332 Outline for Otologic Testing	Form and Instruction	Modified	Available
Form ca-16 Authorization for Examination and/or Treatment	Form and Instruction	Modified	Repair queued
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-17 Duty Status Report	Form and Instruction	Modified	Repair queued
Form CA-7 Claim for Compensation	Form and Instruction	Modified	Available
Attachment 1- Summary Document of Form Revisions.docx	Supplementary Document	Uploaded 2017-10-30	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	Repair queued
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 2018.doc	Supporting Statement A	Uploaded 2018-02-26	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 to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Outline for Otologic Testing
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	Duty Status Report
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Claim for Compensation
13770	FECA Medical Report Forms, Claim for Compensation	Instruction	Modified

ICR Details

OMB Control No: 1240-0046	ICR Reference No: 201701-1240-002
Status: Historical Active	Previous ICR Reference No: 201602-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Federal Employees' Compensation Act Medical Reports and Compensation Claims
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/08/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/24/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved	03/31/2018
Responses	282,353	0	282,353
Time Burden (Hours)	25,605	0	25,605
Cost Burden (Dollars)	110,118	0	110,118

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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:
	82 FR 36159	08/03/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 55878	11/24/2017
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	CA-1332, CA-1331 with CA-1087 enclosure, OWCP-5a, ca-20, owcp-5c, ca-16, owcp-5b, CA-7, CA-17	Claim for Compensation ,   Duty Status Report ,   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 ,   Outline for Otologic Testing ,   Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments

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

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

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 11/24/2017

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