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
Occupational Employment and Wage Statistics.docx Supplementary Document	2023-03-20
81 Fed. Reg 47418 (July 21, 2016).pdf Supplementary Document	2023-03-20
Supporting Statement for 1240-0046-- final.docx Supporting Statement A	2023-06-06
2023 GS Pay Chart.pdf Supplementary Document	2023-03-20
Federal Employees' Compensation Act _ U.S. Department of Labor.html Supplementary Document	2023-03-20

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: 202303-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202206-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Federal Employees' Compensation Act Medical Reports and Compensation Claims
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/11/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2024
Responses	282,353	282,353
Time Burden (Hours)	25,605	25,605
Cost Burden (Dollars)	133,412	122,824

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Abstract: 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).

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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:
	88 FR 16038	03/15/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 44156	07/11/2023
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, CA-1305, CA-1090, 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 Attendant Services (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)	133,412	122,824	0	0	10,588	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: $1,218,781

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: 07/11/2023

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