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Agenda
Reg Review
ICR
View Information Collection (IC)
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 10.331
20 CFR 10.102
20 CFR 10.506
20 CFR 10.300
20 CFR 10.211
20 CFR 10.314
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
Claim for Compensation
CA-7.pdf
http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
No
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 revised 2-16-2018.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 revised february 16, 2018.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 revised 2-16-2018.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.pdf
No
Paper Only
Instruction
CA-1305 9 2017.rtf
No
Paper Only
Form and Instruction
CA-1332
Outline for Otologic Testing
CA-1332 revision 2017 revised 9-2017.docx
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 9-2017cpc.rtf
No
Paper Only
Instruction
CA-1090 revised 2-16-2018.rtf
No
Paper Only
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:
67 FR 16826
Number of Respondents:
282,353
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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)
110,118
0
0
0
0
110,118
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.