Information Collection

FECA Medical Report Forms, Claim for Compensation

IC 13770 under ICR 202412-1240-001 · OMB 1240-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-7 revised FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-7 revised Claim for Compensation FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-17 Duty Status Report FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Conditions FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form owcp-5c Work Capacity Evaluation Form, Musculoskeletal Conditions FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-20 Attending Physicians Report FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form ca-16 Authorization for Examination and/or Treatment FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-1305 Letter to doctor authorizing an eye exam with PPI rating FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-1332 Outline for Otologic Testing FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-1331 with CA-10 Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-1090 Claimant Request for Attendant Services (CA-1090) FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-17 Duty Status Report FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form CA-20 Attending Physicians Report FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form OWCP-5a Work Capacity Evaluation Psychiatric/Psychological Conditions FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form OWCP-5b Work Capacity Evaluation Cardiovascular/Pulmonary Conditions FECA Medical Report Forms, Claim for Compensation	Form and Instruction
Form OWCP-5c Work Capacity Evaluation Musculoskeletal FECA Medical Report Forms, Claim for Compensation	Form and Instruction
CA-7 revised Claim for Compensation CA-7 (Revised) 11-21.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-7 revised Claim for Compensation CA-7 (Revised) 11-21.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-17 Duty Status Report ca-17.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-17 Duty Status Report ca-17.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Cond OWCP-5a.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Cond OWCP-5a.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Condi OWCP-5b.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Condi OWCP-5b.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
owcp-5c Work Capacity Evaluation Form, Musculoskeletal Condition OWCP-5c.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Form and Instruction
owcp-5c Work Capacity Evaluation Form, Musculoskeletal Condition OWCP-5c.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Form and Instruction
CA-20 Attending Physicians Report ca-20.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-20 Attending Physicians Report ca-20.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
ca-16 Authorization for Examination and/or Treatment CA-16 final.pdf www.dol.gov/agencies/owcp/FECA/regs/compliance/forms.	Form and Instruction
ca-16 Authorization for Examination and/or Treatment CA-16 final.pdf www.dol.gov/agencies/owcp/FECA/regs/compliance/forms.	Form and Instruction
CA-1305 Letter to doctor authorizing an eye exam with PPI rating CA-1305.rtf	Form and Instruction
CA-1305 Letter to doctor authorizing an eye exam with PPI rating CA-1305.rtf	Form and Instruction
CA-1332 Outline for Otologic Testing CA-1332 final.rtf	Form and Instruction
CA-1332 Outline for Otologic Testing CA-1332 final.rtf	Form and Instruction
CA-1331 with CA-10 Authorization to Doctor for Audiologic and Otologic Eval CA-1331 final.pdf	Form and Instruction
CA-1331 with CA-10 Authorization to Doctor for Audiologic and Otologic Eval CA-1331 final.pdf	Form and Instruction
CA-1090 Claimant Request for Attendant Services (CA-1090) Claimant Request for Attendant Services.docx	Form and Instruction
CA-1090 Claimant Request for Attendant Services (CA-1090) Claimant Request for Attendant Services.docx	Form and Instruction
CA-17 Duty Status Report ca-17_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-17 Duty Status Report ca-17_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-20 Attending Physicians Report ca-20_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-20 Attending Physicians Report ca-20_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5a Work Capacity Evaluation Psychiatric/Psychological Condi owcp-5a_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5a Work Capacity Evaluation Psychiatric/Psychological Condi owcp-5a_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5b Work Capacity Evaluation Cardiovascular/Pulmonary Condit owcp-5b_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5b Work Capacity Evaluation Cardiovascular/Pulmonary Condit owcp-5b_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
OWCP-5c Work Capacity Evaluation Musculoskeletal owcp-5c_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Form and Instruction
OWCP-5c Work Capacity Evaluation Musculoskeletal owcp-5c_ES.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

FECA Medical Report Forms, Claim for Compensation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.506 20 CFR 10.102 20 CFR 10.331 20 CFR 10.300 20 CFR 10.314 20 CFR 10.211

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-7 revised	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	Yes	Fillable Printable
Form and Instruction	CA-17	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	OWCP-5a	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	owcp-5b	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	owcp-5c	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Yes	No	Fillable Printable
Form and Instruction	CA-20	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	ca-16	https://www.dol.gov/agencies/owcp/FECA/regs/compliance/forms.	No		Paper Only
Form and Instruction	CA-1305		No		Paper Only
Form and Instruction	CA-1332		No		Paper Only
Form and Instruction	CA-1331 with CA-1087 enclosure		No		Paper Only
Form and Instruction	CA-1090		No		Paper Only
Form and Instruction	CA-17	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-20	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	OWCP-5a	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	OWCP-5b	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	OWCP-5c	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm ca-5c.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 282,353

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	282,353	282,353
Annual IC Time Burden (Hours)	25,605	25,605
Annual IC Cost Burden (Dollars)	133,412	133,412

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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