Supp Stmt 1240-0046 final

FECA Medical Report Forms, Claim for compensation

1240-0046

March 31, 2021

Supporting Statement

FECA Medical Report Forms, Claim for Compensation

1240-0046

This ICR seeks to request an EXTENSION

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 Worker’s Compensation Programs (OWCP) administers the Federal Employees’ Compensation Act (FECA), which provides for continuation of pay or compensation for work related injuries or disease from federal employment. 5 U.S.C. § 8149, Congress gives the Secretary of Labor authority to prescribe the rules and regulations necessary for the administration and enforcement of the FECA.

The relevant statutory provision allowing for an individual to make a claim for compensation benefits is found at 5 U.S.C. §8102, Compensation for disability or death of employee, and reads as follows:

(a) The United States shall pay compensation as specified by this subchapter for the disability or death of an employee resulting from personal injury sustained while in the performance of his duty, unless the injury or death is—

(1) caused by willful misconduct of the employee;

(2) caused by the employee's intention to bring about the injury or death of himself or of another; or

(3) proximately caused by the intoxication of the injured employee.

(b) Disability or death from a war-risk hazard or during or as a result of capture, detention, or other restraint by a hostile force or individual, suffered by an employee who is employed outside the continental United States or in Alaska or in the areas and installations in the Republic of Panama made available to the United States pursuant to the Panama Canal Treaty of 1977 and related agreements (as described in section 3(a) of the Panama Canal Act of 1979), is deemed to have resulted from personal injury sustained while in the performance of his duty, whether or not the employee was engaged in the course of employment when the disability or disability resulting in death occurred or when he was taken by the hostile force or individual.  This subsection does not apply to an individual—

(1) whose residence is at or in the vicinity of the place of his employment and who was not living there solely because of the exigencies of his employment, unless he was injured or taken while engaged in the course of his employment; or

(2) who is a prisoner of war or a protected individual under the Geneva Conventions of 1949 and is detained or utilized by the United States.

The relevant statutory provision 5 U.S.C. § 8103, Medical services and initial medical and other benefits, which reads as follows:

(a) The United States shall furnish to an employee who is injured while in the performance of duty, the services, appliances, and supplies prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of the monthly compensation. These services, appliances, and supplies shall be furnished--

(1) whether or not disability has arisen;

(2) notwithstanding that the employee has accepted or is entitled to receive benefits under subchapter III of chapter 83 of this title or another retirement system for employees of the Government; and

(3) by or on the order of United States medical officers and hospitals, or, at the employee's option, by or on the order of physicians and hospitals designated or approved by the Secretary. The employee may initially select a physician to provide medical services, appliances, and supplies, in accordance with such regulations and instructions as the Secretary considers necessary, and may be furnished necessary and reasonable transportation and expenses incident to the securing of such services, appliances, and supplies. These expenses, when authorized or approved by the Secretary, shall be paid from the Employees' Compensation Fund.

(b) The Secretary, under such limitations or conditions as he considers necessary, may authorize the employing agencies to provide for the initial furnishing of medical and other benefits under this section. The Secretary may certify vouchers for these expenses out of the Employees' Compensation Fund when the immediate superior of the employee certifies that the expense was incurred in respect to an injury which was accepted by the employing agency as probably compensable under this subchapter. The Secretary shall prescribe the form and content of the certificate.

References: 5 U.S.C. § 8102, 5 U.S. C. § 8103, and 5 U.S.C. § 8149 . 20 CFR 10.102, 20 CFR 10.211, 20 CFR 10.300, 20 CFR 10.314, 20 CFR. 314, and 20 CFR. 10.506.(See https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm#).

(See https://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&SID=c131552afa82be329e42e2c9d62a41c8&rgn=div5&view=text&node=20:1.0.1.2.2&idno=20)

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 information collected by these forms is used by claims examiners for OWCP to determine eligibility for and the computation of benefits. The claim forms, with the medical evidence, are used to determine whether or not the claimant is entitled to compensation for disability for work or permanent impairment of a scheduled member; the appropriate period, rate of pay, compensation rate, any concurrent employment or dual benefits, and third party credit. The OWCP-5 forms are also used by rehabilitation specialists and nurses to assist partially disabled employees to return to suitable employment. Without the requested information, entitlements to an eligible beneficiary could be denied or delayed, or benefits could be authorized at an incorrect rate, resulting in an underpayment or overpayment of compensation.

The CA-7 (Claim for Compensation), requests information allowing OWCP to fulfill its statutory requirements for the period of compensation claimed, e.g., the pay rate, dependents, earnings, dual benefits and third party information. The CA-7 is used to claim compensation (20 CFR 10.102). The front page is completed by the claimant. On the back page, the employing agency verifies the accuracy of the claimant's statements and provides relevant information from agency records. If a previous CA-7 claim has been made, only certain sections of the form are completed for subsequent claims.

 

In the vast majority of cases, compensation is claimed while a claimant continues to be employed by the Federal Government. In those cases, the CA-7 is completed by a Federal employee and their supervisor, therefore not affecting the public, as contemplated under the PRA. See 5 CFR 1320.3(c) (3). The CA-7 is required of a member of the public on rare occasions, such as when compensation is claimed after the claimant's Federal employment has been terminated. It is estimated that no more than 500 of these forms are required of members of the public through the course of a year. This request for clearance by OMB only pertains to a small percentage of the overall use of the CA-7.

The other forms in this clearance collect medical information necessary to determine entitlement to benefits under the FECA. Before compensation may be paid, the case file must contain medical evidence showing that the claimant's disability is causally related to the claimant's federal employment. As a particular claim ages, there is a continuing need for updated information to support continuing benefits. The various forms included in this ICR and the purpose of each are listed below:

CA-16, Authorization for Examination and/or Treatment – is generated by the employing agency, and authorizes the injured employee to seek immediate medical treatment upon sustaining a workplace injury. The form is in two parts; Part A is a completed authorization from the Federal employer; Part B is a medical report (which is further transmitted to OWCP) completed by the physician who first treats the injured employee (20 CFR 10.211, 10.300 and 10.331).

CA-17, Duty Status Report – Part A is completed by the injured worker’s supervisor and referred to the treating physician for completion of Part B. The form is used on a periodic basis, so that an assessment of the employee's condition and ability to perform work can be monitored (20 CFR 10.506).

CA-20, Attending Physician’s Report – The claimant uses this form to obtain medical documentation from the attending physician to support disability (20 CFR 10.331).

CA-1090 refers to a request for the services of an Attendant, in which there is medical documentation from a physician that the claimant requires assistance to care for personal needs such as bathing, dressing, eating, etc. This letter is locally generated from DFEC Correspondence Library, and asks factual information from the claimant and requests that the claimant refer this letter to their treating physician to determine if the claimant is entitled to the services of an attendant (20 CFR 10.314).

CA-1305 is a referral to a medical specialist involving injury to an eye to the extent of claimant's loss of vision. This letter may also be used if the report is being requested from the claimant's current attending physician or from a physician to whom the claimant is being referred for examination by the servicing district office. While this form letter is used very infrequently, it helps claims examiners develop a very difficult issue and is therefore remaining in inventory.

CA-1087, CA-1331 – The CA-1087 specifies OWCP requirements for audiologic examination and is enclosed with the Form CA-1331 when a claimant is referred for a complete audiologic and otologic examination when a claim for hearing loss has been filed.

CA-1332, Outline for Audiologic Examination, is used to obtain a complete report of audiologic and otologic examination. Use of the CA-1332 outline is optional, but when used, it should simplify the process of developing the report for the respondent and result in an improved report.

OWCP-5a, Work Capacity Evaluation, Psychiatric/Psychological Conditions -- Used to obtain the claimant's specific work tolerance limitations where the accepted condition is psychiatric or psychological in nature. It may also be used as an attachment to any original or form letter seeking work limitations.

OWCP-5b, Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions -- Used to obtain claimant's work tolerance limitations where the accepted condition is cardiovascular or pulmonary in nature. It may also be used as an attachment to an original or form letter seeking work limitations.

OWCP-5c, Work Capacity Evaluation, Musculoskeletal Conditions -- Used to obtain the claimant's work tolerance limitations when the accepted condition is musculoskeletal in nature. It may also be attached to any original or form letter which seeks work limitations.

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.

In accordance with the Government Paperwork Elimination Act (GPEA), the Division of Federal Employees’ Compensation seeks to allow individuals and entities that deal with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate.

To improve upon the capabilities for the general public to submit DFEC documents, the agency has an electronic feature that is Internet based which allows a user to submit non-medical and medical documents such as the CA-7, CA-17, CA-20, and the OWCP-5s electronically to a claim. This application is available to the claimant, employing agency, and the medical provider and there is no cost to the user. See https://www.ecomp.dol.gov/#

When filing a CA-7 electronically, the user will be able to input data to complete their portion of the form that matches the CA-7 paper form. Once data is input, the form can be downloaded and printed, and will appear as the exact same CA-7 form that will appear on the DFEC website.

Please note that forms CA-7, CA-17, CA-20, and the OWCP-5s will remain available at the web link below and maybe printed and electronically filled for mail or fax to the appropriate DFEC district office.

http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

Forms CA-1090, CA-1305, CA-1331, CA-1332(CA-1087) are all generated solely by the government agency (OWCP) and not the general public.

Form CA-16 is initiated solely by the employing agency and is not available on line for download or electronic submission as it is not a public use form.

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 these forms is not duplicative of any information available elsewhere. The claimant, their employer, and their physician are the only sources of the required information. The forms have been streamlined over the years to obtain the necessary medical information while imposing the minimum burden on the respondent. 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, or was collected less frequently, OWCP would be unable to properly provide disability benefits to injured Federal employees. If benefits were paid in the absence of full information, there would be numerous incorrect payments, creating overpayments, and depriving claimants of benefits to which they are entitled.

7. Explain any special circumstance required in the conduct of the information collection to be conducted in a manner:

.

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentially that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentially to the extent permitted by law.

Special circumstances which apply to this ICR are as follows:

a. Medical information necessary to determine entitlement to benefits is requested on an as-needed basis. Therefore, respondents often are required to provide information more frequently than quarterly. The need for updating this information is constant. As the medical status of a claimant changes over time, updated medical information must be requested to determine continuing entitlement to compensation.

For example, a claimant who has been paid compensation for specific periods may file a claim for a subsequent period of disability. In order to determine if the claimant is entitled to compensation for that period, the claimant must submit medical documentation pertaining to the period. The OWCP reviews this medical information and uses it to make a decision as to whether or not the claimant is entitled to compensation for the period claimed.

b. Often, medical information is needed from the respondent in less than thirty days. For instance, medical information is needed in order to adjudicate a claim and pay compensation. If the claimant is off work and without income, the prompt submission of the medical needed to support the claim will reduce the financial hardship of the respondent. Also, medical information is needed quickly so that medical treatment and surgeries can be timely authorized and reduce the recovery time of the respondent.

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. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting comment was published on November 13, 2020. [85 FR 72701]. Comments were not received.

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 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. 47418 (July 21, 2016)]. The Privacy Act Statement has been added to the various forms that are 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.

All information submitted on these forms are fully protected under the Privacy Act in the following systems of records: DOL/GOVT-1, 81 FR 47418 (July 21, 2016). A Privacy Act Statement is included in each of the forms.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• 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 conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. General, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Burden Costs: CA-7 Forms: The cost to the respondent for completing Form CA-7 is determined by using the National Average Hourly Earnings of Private Production Workers – not seasonally adjusted as computed by BLS of $25.26 per hour. The respondent time for the CA-7 is 120 hours for a cost of $2,471.

See: http://www.bls.gov/web/empsit/ceseeb8b.htm

Burden Hours: Burden hour estimates have been derived from actual respondent usage of these forms/letters. Each estimate represents an average amount of time it takes one respondent to complete one form/letter. For example, in the case of the CA-1332, the burden hours estimate is based as follows: 11 (number of respondents) times 1 (number of responses per respondent) times the average time to complete the letter per response, i.e., (thirty minutes) divided by 60, which equates to 5.5 or 6 burden hours, rounded up.

Medical Forms Only: 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 $19.73 (BLS, Occupational Employment and Wages Occupational Code 43-0000 for Office and Administrative Support Occupations, 2021). The total respondent time for the medical report forms is 25,485 hours, for a cost of $427,638 (25,485 X $19.73).

See: http://www.bls.gov/oes/current/oes430000.htm

The total respondent cost for medical forms and the CA-7: $427,638 + $2,471 = $430,109.

*Responses and hours associated with Form CA-1087 are included in the estimates for the Form CA-1331. The Form CA-1087 is attached to the Form CA-1331.

** http://www.bls.gov/web/empsit/ceseeb8b.htm (for private production workers)

http://www.bls.gov/oes/current/oes430000.htm (for physician staffers)

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent		Total Responses		Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Total Burden Cost
CA-7	553	1		553		13/60	120	$25.26	$3,031
MEDICAL REPORT FORMS
CA-16	29,519	1		29,519		5/60	2,460	$19.73	$48,536
CA-17	182,793	1		182,793		5/60	15,233	$19.73	$300,547
CA-20	56,394	1		56,394		5/60	4,700	$19.73	$92,731
CA-1332	11	1		11		30/60	6	$19.73	$118
CA-1090	234	1		234		10/60	39	$19.73	$769
CA-1305	136	1		136		20/60	45	$19.73	$888
CA-1331/ CA-1087*	1,062	1		1,062		5/60	89	$19.73	$1,756
OWCP-5s	11,651	1		11,651		15/60	2,913	$19.73	$57,473
TOTAL	282,353		--		282,353	--	25,605		$505,849

• *Responses and hours associated with Form CA-1087 are included in the estimates for the Form CA-1331. The Form CA-1087 is attached to the Form CA-1331.

13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital and startup cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of service component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

Twenty-five percent of the responses are expected come in via an electronic portal. These respondents are not expected to incur any costs under this item. The remaining percentage will file their documents via mail or fax and incur associated costs.

Number of respondents-electronic means:

282,353 (total number of respondents) x.25 percent (electronic submitted) = 70,588

Number of respondents-mail/fax:

282,353 minus 70,588 = 211,765.

A total of 211,765 responses at $0.58 ($0.55 postage + $.03 envelope) per response = $122,824.

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

The estimated costs to the Federal government of collecting these forms are set out below:

Process/Review Costs:

The average hourly wage for the reviewer is that of a GS-12/6, $48.75 per hour (Federal Salary Table for Rest of US, 2021). These respondents reflect those who submitted documents via mail or via the DFEC web link electronically as noted in item 3.

See http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2014/RUS_h.pdf

Time to review each form is noted below

Time Total

Form to Review Respondents Cost

CA-7 13 min. 553 $5,841

CA-16 5 min. 29,519 $119,921

CA-17 5 min. 182,793 $742,597

CA-20 5 min. 56,394 $229,101

CA-1090 10 min. 234 $1,901

CA-1305 20 min. 136 $2,210

CA-1331 5 min. 1,062 $4,314

CA-1332 30 min. 11 $268

CA-1087 30 min. 1,062 $25,886

Cost Only

OWCP-5s 15 min. 11,651 $141,997

Total Review Cost $ 1,274,036

Postage cost: (most of these forms are enclosures or are hand carried to the claimant by the federal employer). It is estimated that approximately 1,000 are mailed each year separately:

1,000 x $.55 = $550.00.

Total Federal Cost: $1,274,586 ($1,274,036 + 550.00 mailing costs)

15. Explain the reasons for any program changes or adjustments.

There are no program changes or adjustments to this information collection. The $12,706 increase in cost burden is due entirely to increases mailing costs in comparison to the last clearance period.

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.

There are no plans to publish data collected by these forms.

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.

This information collection request does not seek a waiver from the requirement to display the expiration date.

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.