Peace Corps Volunteer Authorization for Examination and/or Treatment
1240-0059
August 2020
Supporting Statement
Peace Corps Volunteer Authorization for Examination and/or Treatment
1240-0059
Revision
A. Justification.
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.
The Office of Workers' Compensation Programs (OWCP) administers the Federal Employees' Compensation Act (FECA), 5 U.S.C. 8101 et seq. The statute provides for the payment of benefits for wage loss and/or for permanent impairment to a scheduled member, arising out of a work related injury or disease. The Act outlines the elements of pay which are to be included in an individual's pay rate, and sets forth various other criteria for determining eligibility to and the amount of benefits, including: augmentation of basic compensation for individuals with qualifying dependents; a requirement to report any earnings during a period that compensation is claimed; a prohibition against concurrent receipt of FECA benefits and benefits from OPM or certain VA benefits; a mandate that money collected from a liable third party found responsible for the injury for which compensation has been paid is applied to benefits paid or payable. See
http://www.access.gpo.gov/nara/cfr/waisidx_10/20cfr10_10.html
A Peace Corps Volunteer who sustains an injury or contracts an illness overseas while in Peace Corps service may be entitled to benefits under the FECA. Peace Corps Volunteers are considered to be in the performance of duty while abroad during the period of Peace Corps service for purposes of FECA coverage. An injury sustained outside the United States during service is deemed proximately caused by such service, unless the injury or illness was proximately caused by willful misconduct, intention to bring about injury or death, or intoxication.
The Sam Farr and Nick Castle Peace Corps Reform Act of 2018 (Farr-Castle), modified various aspects of the Peace Corps, including changes to the provision of health care to volunteers. The legislation is named in honor of former Peace Corps volunteers Sam Farr, a retired Democratic congressman, and Nick Castle, who lost his life at age 23 while serving overseas in the Peace Corps in 2013.
The Peace Corps was established on September 22, 1961, by Public Law 87-293, known as the "Peace Corps Act." It authorizes the enrollment of qualified citizens and nationals of the United States as "volunteers" and "volunteer leaders" for service abroad in interested countries and areas, to help the people of such countries and areas in meeting their needs for trained workers, and to help promote a better understanding of the American people on the part of the peoples served and a better understanding of other peoples on the part of the American people.
Under the provisions of the FECA, 5 U.S.C. §8142 of the FECA provides that,
(a) For the purpose of this section, "volunteer" means--
(1) a volunteer enrolled in the Peace Corps under section 2504 of title 22;
(2) a volunteer leader enrolled in the Peace Corps under section 2505 of title 22; and
(3) an applicant for enrollment as a volunteer or volunteer leader during a period of training under section 2507(a) of title 22 before enrollment.
Entitlement to disability compensation payments does not commence until the day after the date of termination of service as a volunteer. 5 U.S.C. 8142(b).
Farr-Castle directs the Secretary of the Department of Labor to authorize the Director of the Peace
Corps to furnish medical benefits to a volunteer, who is injured during the volunteer’s period of service, for a period of 120 days following the termination of such service if the Director certifies that the volunteer’s injury probably meets the requirements set forth in 5 U.S.C. 8142(c)(3). The Secretary may then certify vouchers for these expenses for such volunteer out of the Employees’ Compensation Fund.
Reference: Sam Farr & Nick Castle Peace Corps Reform Act of 2018, Pub. L. No. 115-256, § 102, 132 Stat. 3650 (2018) (codified as amended at 5 USCA § 8142).
In view of the provisions required by passage of this bill, the (OWCP and the Peace Corps have collaborated to initiate a new form that will authorize medical treatment for recently terminated Peace Corps volunteers who require medical treatment for injuries/exposure sustained in the performance of their volunteer service. Issuance of this form will solely be at the discretion of the Peace Corps, and will bridge a gap between the occurrence of an initial injury and/or disease exposure and the actual adjudication of a claim by OWCP by helping ensure that recently terminated volunteers receive prompt medical care, without delay, for a period of 120 days following separation from service. This form will be described as follows:
CA-15, Peace Corps Volunteer Authorization for Examination and/or Treatment
As noted, this form will be generated by the Peace Corps and authorizes an injured recently terminated Peace Corps volunteer to seek immediate medical treatment upon sustaining an injury proximately caused by their voluntary service. The form is intended to authorize the provision of medical treatment, primarily in the United States, for up to 120 days following termination of Peace Corps service. The form is in two parts; Part A is a completed authorization form from the Peace Corps’ Office of Health Services; Part B is a medical report (which is transmitted to OWCP) completed by the physician who first treats the injured Peace Corps volunteer. It is requested that this ICR be given priority consideration so that the form can be in use by March 2020.
2. Indicate how, by whom, and for what purpose the information is to be used. Except for new collection, indicate the actual use the agency has made of the information received from the current collection.
The CA-15 will be a vehicle by which the Peace Corps authorizes initial examination and/or medical treatment at OWCP expense. This form will allow treatment for up to 120 days following date of separation from the Peace Corps, a period during which OWCP has a legal obligation to pay for medical services. Once a case is accepted by OWCP, the period of authorization is automatically extended to cover necessary services for the accepted conditions, and additional authorization is not necessary unless requested by a provider in a specific case. If a case is denied, however, authorization is revoked for further treatment even though 120 days may have not elapsed. However, OWCP may approve payment of medical expenses on a case by case basis if a CA-15 has not been issued and the claim is subsequently denied.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burdens.
Presently, this form will not be available on the OWCP website for the public to download or for transmission by electronic means to protect against potential fraud and abuse. The form will solely be initiated by a Peace Corps official who has been approved to authorize emergency care for recently terminated volunteers. This form will be available to authorized Peace Corps personnel, and may be obtained in electronic format via the Agency Query System (AQS).
Reference: https://aqsweb.dol-esa.gov/AQS/login.html
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.
The information requested on this form is not duplicative of any information available elsewhere. The volunteer, the Peace Corps, and their physician are the only sources of the required information. In addition, the information is not collected unless the information is necessary for the adjudication of the case.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
This information collection does not have a significant economic impact on a substantial number of small entities.
6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
If this information was not collected, OWCP would be unable to properly provide medical benefits to injured, recently terminated Peace Corps volunteers.
7. Explain any special circumstance required in the conduct of the information collection.
There are no special circumstances for the collection of this information.
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
A Federal Register notice inviting public comment was published on August 7, 2019 (84 FR 38671). One public comment was received.
The Chief Executive Officer with the American Association of Nurse Practitioners, in a letter dated October 7, 2019, raised concerns that the proposed form only allows a qualified physician, and not Nurse Practitioners, permission to complete this form. The author further notes that other federal agencies, such as the Veterans Administration and the Social Security Administration permit Nurse Practitioners, as acceptable medical sources to establish medical physical or mental impairment.
OWCP Response:
To allow Nurse Practitioners to sign the CA-15 would require an amendment to the Federal Employees’ Compensation Act (8101 et seq) and require Congressional approval. Therefore, OWCP does not have authority to expand the Nurse Practitioners role in this regard at this time.
For entitlement to federal employees’ compensation benefits, 5 U.S.C. 8103 (a) of FECA requires a qualified physician to proscribe or recommend medical care and services which are likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of monthly compensation. Such medical services include medical treatment, including surgery and hospitalization as well as appliances and supplies.
Under 5 U.S.C. 8101 (2), FECA defines physician as surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law. The term "physician" includes chiropractors only to the extent that their reimbursable services are limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist, and subject to regulation by the Secretary.
However, FECA’s implementing regulations, 20 CFR Section 10.310 (a) also provides in pertinent part that,
Non-physician providers such as physicians' assistants, nurse practitioners, and physical therapists may also provide authorized services for injured employees to the extent allowed by applicable Federal and State law.
OWCP recognizes the importance and the critical link that Nurse Practitioners and other health care personnel are to our program and thank them for excellence in service.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents, other than required payments to contractors.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations or agency policy.
The information collected by these forms is maintained in FECA claim files, which are fully protected under the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1 [81 Fed. Reg. 418 (July 21, 2016)]. The Privacy Act Statement has been added to this form associated with this information collection. See http://www.dol.gov/sol/privacy/dol-govt-1.htm.
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
No questions regarding sexual behavior, religious beliefs, etc. are asked. The social security and medical information collected would be considered sensitive, but is essential for proper evaluation of entitlement to benefits. Authority to collect Social Security Numbers is provided by P.L. 106-113, page 258.
Reference: https://www.gpo.gov/fdsys/pkg/PLAW-106publ113/html/PLAW-106publ113.htm
12. Indicate the number of respondents, frequency of response, annual hour burden and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information.
Note: This revision requires respondents to be registered users of the web portal to electronically upload documents into a case record. The time to input this information is very minimal, less than one minute, and therefore does not impact the current burden estimates. See below.
Estimated Annualized Respondent Cost and Burden Hours
Form # |
Total Number of Responses |
Average Burden Per Response (Hours) |
Total Hour Burden |
Average Hourly Wage Rate |
Total Cost Burden |
CA-15 |
252 |
.25 |
63 |
$18.02 |
$1, 135.00 |
Reference: http://www.bls.gov/oes/current/oes430000.htm (for physician staffers)
Burden Hours: Burden hour estimates are derived from estimated actual respondent usage of this form. Each estimate represents an average amount of time it takes one respondent to complete one form. For example, the burden hours estimate is based as follows: 252 (number of respondents) times 1 (number of responses per respondent) times the average time to complete the letter per response, i.e., (fifteen minutes)divided by 60, which equates to 63 burden hours.
Burden Costs:
Medical report forms are generally completed by administrative support staff based on physician's notes for the signature of the physician. The cost to the respondent on the completion of the medical forms is estimated based upon the mean wage rate of $18.02 (BLS, Occupational Employment and Wages Occupational Code 43-9199 for Office and Administrative Support Occupations, May 2018). The total respondent time for the medical report forms is 63 burden hours, for a cost of $1,135.00 (63 X $18.02).
Reference: https://www.bls.gov/oes/current/oes439199.htm
The total respondent cost to complete this form is $1, 135.00.
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
Number of respondents-mail/fax: A total of 252 responses at $.55 postage + $.03
envelope = $.58 – per response (postage and envelope) = $146.00.
14. Provide estimates of annualized cost to the Federal government.
Federal Cost Estimate:
Review Costs: The average hourly wage for the reviewer from the Cleveland district office is $40.94 (GS-12/4). These respondents reflect those who submitted documents via mail or fax.
FORM # |
Time to Review |
Total Respondents |
Costs |
CA-15 |
15 minutes |
252 |
$2, 579.00 |
Total Review Costs = $2, 579.00 (15/60 x 252 x $40.94)
Total Postage Cost: $146.00 (252 responses @ .55 postage + $.03
envelope = $.58 – per response (postage and envelope)
Total Federal Cost: $2,725.00 ($2, 579. 00 + $146.00 postage/mailing costs)
Reference: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2019/CLE_h.pdf
15. Explain the reasons for any program changes or adjustments.
This is a new collection request based on an amendment to the FECA. The current practice is that a copy of the form and medical documentation be returned to our central mailroom location in London, Kentucky. However, the central mailroom is changing address and we anticipate operations to begin by the middle of April 2020.
The program is requesting that the new address, OWCP/DFEC, P.O. Box 34090, San Antonio, Texas 78265, be approved prior to the middle of April 2020 to ensure both the employing agency and the treating physician use the correct form. This will also ensure that OWCP also receives the necessary documentation to assist in administering this part of the program without any delays in medical treatment or payments to the injured volunteer and the treating physician.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
Data collected with these forms will not be published.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
DOL/OWCP/DFEC is not seeking an exemption to display the expiration date on the CA forms.
18. Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods
This information collection does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement |
| Author | US Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |