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 CA-7 revised 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-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-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
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-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-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-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
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-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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-7 revised	Claim for Compensation	CA-7 (Revised) 11-21.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
Form and Instruction	CA-17	Duty Status Report	ca-17_ES.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-20	Attending Physicians Report	ca-20_ES.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_ES.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_ES.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	OWCP-5c	Work Capacity Evaluation Musculoskeletal	owcp-5c_ES.pdf	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 %

	Requested	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

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.