Federal Employees' Compensation Act Medical Reports and Compensation Claims

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OWCP-5c Work Capacity Evaluation Musculoskeletal	Form and Instruction	Modified	Available
Form OWCP-5b Work Capacity Evaluation Cardiovascular/Pulmonary Conditions	Form and Instruction	Modified	Available
Form OWCP-5a Work Capacity Evaluation Psychiatric/Psychological Conditions	Form and Instruction	Modified	Available
Form CA-20 Attending Physicians Report	Form and Instruction	Modified	Available
Form CA-17 Duty Status Report	Form and Instruction	Modified	Available
Form CA-1090 Claimant Request for Attendant Services (CA-1090)	Form and Instruction	Modified	Available
Form CA-1331 with CA-10 Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments	Form and Instruction	Modified	Available
Form CA-1332 Outline for Otologic Testing	Form and Instruction	Modified	Available
Form CA-1305 Letter to doctor authorizing an eye exam with PPI rating	Form and Instruction	Modified	Available
Form ca-16 Authorization for Examination and/or Treatment	Form and Instruction	Modified	Available
Form CA-20 Attending Physicians Report	Form and Instruction	Modified	Available
Form owcp-5c Work Capacity Evaluation Form, Musculoskeletal Conditions	Form and Instruction	Modified	Available
Form owcp-5b Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions	Form and Instruction	Modified	Available
Form OWCP-5a Work Capacity Evaluation, Psychiatric/Psychological Conditions	Form and Instruction	Modified	Available
Form CA-7 revised Claim for Compensation	Form and Instruction	Modified	Available
Employment and Earnings Table B-8b.bls. National Avg Hrly Earnings of Private Production Workers - not seasonal. Jan. 2026.pdf	Supplementary Document	Uploaded 2026-05-19	Available
OPM RUS Salary Table 2026.pdf	Supplementary Document	Uploaded 2026-05-19	Available
81 Fed. Reg 47418 (July 21, 2016).pdf	Supplementary Document	Uploaded 2026-05-19	Available
Supporting Statement for 1240-0046 2026 OCIO1.clean copy.docx	Supporting Statement A	Uploaded 2026-05-28	Available
FECA.pdf	Supplementary Document	Uploaded 2026-05-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation Musculoskeletal
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation Psychiatric/Psychological Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Attending Physicians Report
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Duty Status Report
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Claimant Request for Attendant Services (CA-1090)
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Authorization to Doctor for Audiologic and Otologic Evaluation OWCP Hearing Loss Requirments
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Outline for Otologic Testing
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Letter to doctor authorizing an eye exam with PPI rating
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Authorization for Examination and/or Treatment
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Attending Physicians Report
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation Form, Musculoskeletal Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Work Capacity Evaluation, Psychiatric/Psychological Conditions
13770	FECA Medical Report Forms, Claim for Compensation	Form and Instruction	Modified	Claim for Compensation

ICR Details

OMB Control No: 1240-0046	ICR Reference No: 202605-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202502-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Federal Employees' Compensation Act Medical Reports and Compensation Claims
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/04/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	279,100	282,353
Time Burden (Hours)	26,648	25,605
Cost Burden (Dollars)	173,740	133,412

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Abstract: These forms are utilized for the submission of claims pertaining to wage loss resulting from Federal employment-related injuries. Additionally, they are required for the collection of essential medical documentation to determine whether a claimant is eligible for benefits under the Federal Employees Compensation Act (FECA).

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Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8102 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8103 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:
	91 FR 13637	03/20/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 33766	06/04/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

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, CA-20, owcp-5c, ca-16, owcp-5b, OWCP-5a, CA-7 revised, CA-17, CA-20, OWCP-5a, OWCP-5b, OWCP-5c	Claim for Compensation ,   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) ,   Duty Status Report ,   Attending Physicians Report ,   Work Capacity Evaluation Psychiatric/Psychological Conditions ,   Work Capacity Evaluation Cardiovascular/Pulmonary Conditions ,   Work Capacity Evaluation Musculoskeletal

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ICR Summary of Burden

table that charts list 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	279,100	282,353	0	-3,253	0	0
Annual Time Burden (Hours)	26,648	25,605	0	1,043	0	0
Annual Cost Burden (Dollars)	173,740	133,412	0	40,328	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Respondents: The number of respondents decreased from 282,353 to 279,100. This decrease in respondents was due to less forms received overall. Responses: The number of responses decreased from 282,353 to 279,100. This decrease in respondents was due to less forms received overall. Burden Hours: The total number of burden hours increased from 25,605 hours to 26,648 hours due to the increased responses for the OWCP-5, CA-16 and CA-1331/CA-1087. Specifically, The number of OWCP-5’s increased from 11,651 to 19,550 The number of CA-16’s decreased from 29,519 to 19,143 The number of CA-1331/CA-1087 increased from 1,062 to 1,540 Burden Hours: The total number of burden hours increased from 25,605 hours to 26,648 hours due to the volume of the increased responses for the OWCP-5, CA-16 and CA1331/CA-1087. Specifically, the number of OWCP-5s increased from 11,651 to 19,550, the number of CA-16s decreased from 29,519 to 19,143, and the number of CA-1331/CA-1087 increased from 1,062 to 1,540. Costs to Respondents or Recordkeepers: Item 13 costs for this submission increased from $133,412 to $173,740 due to an increase in the cost of postal mailing costs, and the hourly rate increase(s) from $28.03 to $32.03 & $20.88 to $23.05. The burden cost increased due to the increase in postage price and the current hourly wage of both the Office and Administrative Support Occupations (Medical report forms are generally completed by administrative support staff based on physician's notes for the signature of the physician) and the National Average Hourly Earnings of Private Production Workers – not seasonal (respondents completing the CA-7 form).

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Annual Cost to Federal Government: $1,342,463

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: 06/04/2026

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