Federal Employees' Compensation Act Medical Reports and Compensation Claims

ICR 202003-1240-005

OMB: 1240-0046

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2020-03-16
Supplementary Document
2020-03-16
Supplementary Document
2020-02-24
Justification for No Material/Nonsubstantive Change
2020-02-24
Justification for No Material/Nonsubstantive Change
2020-02-24
Supplementary Document
2020-02-24
Justification for No Material/Nonsubstantive Change
2018-11-13
Supplementary Document
2017-10-30
Supplementary Document
2014-06-26
Supplementary Document
2014-06-26
Supplementary Document
2014-06-26
Supplementary Document
2014-06-26
Supporting Statement A
2018-02-26
Supplementary Document
2014-06-26
IC Document Collections
ICR Details
1240-0046 202003-1240-005
Historical Active 202002-1240-018
DOL/OWCP
Federal Employees' Compensation Act Medical Reports and Compensation Claims
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/13/2020
Retrieve Notice of Action (NOA) 04/12/2020
  Inventory as of this Action Requested Previously Approved
03/31/2021 03/31/2021 03/31/2021
282,353 0 282,353
25,605 0 25,605
110,118 0 110,118

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.

US Code: 5 USC 8101 et.seq Name of Law: Federal Employees Compensation Act
  
None

Not associated with rulemaking

  82 FR 36159 08/03/2017
82 FR 55878 11/24/2017
No

  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
No
No

$1,015,828
No
    Yes
    Yes
No
No
No
Uncollected
Marcus Sharpless 202 693-0998 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
04/12/2020


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