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 for No material Nonsubstantive Change - 1240-0046 Authorization for Examination and or Treatment (CA-16).docx Justification for No Material/Nonsubstantive Change	2022-06-24
Supp Stmt 1240-0046 final.docx Supporting Statement A	2021-02-24
DOL SORNs list.pdf Supplementary Document	2021-02-22
2021 GS pay chart.pdf Supplementary Document	2021-02-22
30-day FRN (1240-0046) published.pdf Supplementary Document	2021-02-22
60-day FRN (1240-0046) published.pdf Supplementary Document	2021-02-22
OWCP DFEC FECA 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: 202206-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202101-1240-003
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	Date Submitted to OIRA: 06/24/2022

	Requested	Previously Approved
Expiration Date	05/31/2024	05/31/2024
Responses	282,353	282,353
Time Burden (Hours)	25,605	25,605
Cost Burden (Dollars)	122,824	122,824

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Abstract: Requesting an update to form: On the top of the form there is a current reference which states the following, “ If instructions are separated from this form, refer to form information https://www.dol/owcp/dfec.” This link no longer exists, and should be changed to the following: “ https://www.dol.gov/agencies/owcp/FECA/regs/compliance/forms. With regards to the form itself, there are 2 minor changes. On the top of the form there is a current reference which states the following, “ If instructions are separated from this form, refer to form information https://www.dol/owcp/dfec.” This link no longer exists, and should be changed to the following: “ https://www.dol.gov/agencies/owcp/FECA/regs/compliance/formsUpdate to the address on form due to the consolidation of the Division of Federal Employees' Compensation (DFEC) and the Longshore and Harbor Worker's Compensation the new Division is now noted as OWCP Division of Federal Employees', Longshore and Harbor Workers' Compensation (DFELHWC). The address in item 11 should now be noted as Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation, Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA), PO Box 8311, London, KY 4072-8311.

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Authorizing Statute(s): US Code: 5 USC 8103 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8101 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8102 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:
	85 FR 72701	11/13/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 9953	02/17/2021
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-1332, CA-1305, CA-1090, 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 ,   Letter to doctor authorizing an eye exam with PPI rating ,   Outline for Otologic Testing ,   Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments ,   Claimant Request for Attending Physician (CA-1090)

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ICR Summary of Burden

	Total Request	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)	122,824	122,824	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: $1,274,586

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? No

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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: 06/24/2022

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