FECA Medical Report Forms, Claim for Compensation

Federal Employees' Compensation Act Medical Reports and Compensation Claims

OMB: 1240-0046

IC ID: 13770

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

FECA Medical Report Forms, Claim for Compensation
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 10.211 20 CFR 10.102 20 CFR 10.506 20 CFR 10.331 20 CFR 10.300 20 CFR 10.314

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CA-7 Claim for Compensation ca-7.pdf http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes Yes Fillable Printable
Form and Instruction CA-17 Duty Status Report ca-17.pdf http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes No Fillable Printable
Form and Instruction OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Conditions OWCP-5a.pdf http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes No Fillable Printable
Form and Instruction owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions OWCP-5b.pdf http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes No Fillable Printable
Form and Instruction owcp-5c Work Capacity Evaluation Form, Musculoskeletal Conditions OWCP-5c.pdf http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf Yes No Fillable Printable
Form and Instruction CA-20 Attending Physicians Report ca-20.pdf http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm Yes No Fillable Printable
Form and Instruction ca-16 Authorization for Examination and/or Treatment CA-16 final.pdf https://www.dol.gov/agencies/owcp/FECA/regs/compliance/forms. No   Paper Only
Form and Instruction CA-1305 Letter to doctor authorizing an eye exam with PPI rating CA-1305.rtf No   Paper Only
Form and Instruction CA-1332 Outline for Otologic Testing CA-1332 final.rtf No   Paper Only
Form and Instruction CA-1331 with CA-1087 enclosure Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments CA-1331 final.pdf No   Paper Only
Form and Instruction CA-1090 Claimant Request for Attendant Services (CA-1090) Claimant Request for Attendant Services.docx No   Paper Only

Workforce Management Labor Rights Management

DOL/GOVT-1  81 FR 47418

282,353 0
   
Individuals or Households
 
   25 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 282,353 0 0 0 0 282,353
Annual IC Time Burden (Hours) 25,605 0 0 0 0 25,605
Annual IC Cost Burden (Dollars) 133,412 0 0 10,588 0 122,824

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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