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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1240-0046
ICR Reference No:
201406-1240-002
Status:
Historical Active
Previous ICR Reference No:
201204-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Federal Employees' Compensation Act Medical Report Forms, Claim for Compensation
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
01/16/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/31/2014
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2018
36 Months From Approved
01/31/2015
Responses
282,353
0
232,853
Time Burden (Hours)
25,605
0
21,212
Cost Burden (Dollars)
110,118
0
109,441
Abstract:
These forms are used for filing claims for wage loss or permanent impairment due to a Federal employment-related injury, and to obtain necessary medical documentation to determine whether a claimant is entitled to benefits under the Federal Employees Compensation Act (FECA), 5 U S.C. 8101 et.seq.
Authorizing Statute(s):
US Code:
5 USC 8101 et.seq
Name of Law: Federal Employees Compensation Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
79 FR 38073
07/03/2014
30-day Notice:
Federal Register Citation:
Citation Date:
79 FR 64836
10/31/2014
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
FECA Medical Report Forms, Claim for Compensation
owcp-5c, owcp-5b, CA-7, CA-17, CA-1331,with CA-1087 enclosed, CA-1332, OWCP-5a, ca-16, ca-20
Claim for Compensation
,
Duty Status Report
,
Authorization to Doctor for Audiologic and Otologic Evaluation and enclosure PWCP Hearing Loss Medical Requirements
,
Outline for Otologic Testing
,
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
ICR Summary of Burden
Total Approved
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
282,353
232,853
0
0
49,500
0
Annual Time Burden (Hours)
25,605
21,212
0
0
4,393
0
Annual Cost Burden (Dollars)
110,118
109,441
0
0
677
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The responses from the respondents increased from 232,853 to 282,353, which is an adjustment of 49,500 responses. Accordingly, the burden hours increased from 21, 2012, to 25, 605, which is an adjustment of 4,393 burden hours. The burden costs have increased from $109,441 to $110,118, a difference of $677.
Annual Cost to Federal Government:
$1,015,828
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
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?
Uncollected
Agency Contact:
Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov
Common Form ICR:
No
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:
10/31/2014
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