Federal Employees' Compensation Act Medical Reports and Compensation Claims

Forms and Documents

Document Name	Status
Form CA-7 FECA Medical Report Forms, Claim for Compensation Form and Instruction	Modified
Justification - Authorization for Examination and or Treatment (CA-16).docx Justification for No Material/Nonsubstantive Change	2020-03-16
CA-16 Authorization for Examination and or Treatment.pdf Supplementary Document	2020-03-16
CA-20 Attending Physicians Report.pdf Supplementary Document	2020-02-24
Justifiction - CA-20.docx Justification for No Material/Nonsubstantive Change	2020-02-24
Justifiction - CA-17.docx Justification for No Material/Nonsubstantive Change	2020-02-24
CA-17 Duty Status Report.pdf Supplementary Document	2020-02-24
Nonmaterial Change Justification CA-16 november 2018 mjs jv.docx Justification for No Material/Nonsubstantive Change	2018-11-13
Attachment 1- Summary Document of Form Revisions.docx Supplementary Document	2017-10-30
BLS Average hourly and weekly earnings, production and nonsupervisory employees on private nonfarm payrolls omb1240-0046 2014.htm.docx Supplementary Document	2014-06-26
Occupational Employment and Wages Administrative Support-omb1240-0046 2014.docx Supplementary Document	2014-06-26
2014 opm salary table RUS_h, omb 1240-0046 2014.pdf Supplementary Document	2014-06-26
OWCP DFEC FECA omb 1240-0046 2014.docx Supplementary Document	2014-06-26
Supporting Statement 1240-0046 2018.doc Supporting Statement A	2018-02-26
Privacty Act Systems-omb 1240-0046 2014.docx Supplementary Document	2014-06-26

IC Document Collections

IC ID	Document Title	Status
13770	FECA Medical Report Forms, Claim for Compensation Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0046	ICR Reference No: 202003-1240-005
Status: Historical Active	Previous ICR Reference No: 202002-1240-018
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Federal Employees' Compensation Act Medical Reports and Compensation Claims
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/13/2020
	Date Received in OIRA: 04/12/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	03/31/2021	03/31/2021
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: Address change for Duty Status Report (CA-17) and Attending Physician's Report (CA-20) and the Authorization for Examination and/or Treatment (CA-16) only. 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

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

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ICR Summary 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: 04/12/2020

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