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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:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
ca-17
Duty Status Report
ca-17.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf
Yes
No
Fillable Printable
Form and Instruction
CA-7
Claim for Compensation
ca-7.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-7.pdf
Yes
No
Fillable Printable
Form and Instruction
CA-17
Duty Status Report
ca-17.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-17.pdf
Yes
No
Fillable Printable
Form and Instruction
CA-1331
Authorization to doctor for audiologic and otologic evaluation
CA-1331 & CA-1087.doc
No
Paper Only
Instruction
CA-1305.doc
No
Paper Only
Instruction
CA-1303.doc version1.doc
No
Paper Only
Instruction
CA-1090.doc
No
Paper Only
Form and Instruction
CA-1332
Outline for Otologic Testing
CA-1332 outline for otologic testing.doc
No
Paper Only
Instruction
qcm Letter to doctor, no return to work.doc
No
Paper Only
Instruction
qcm letter to doctor (no rtw and nurse assigned).doc
No
Paper Only
Form and Instruction
OWCP-5A
Work Capacity Evaluation
OWCP-5a.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-5a.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
owcp-5b
Work Capacity Evaluation
OWCP-5b.pdf
http://www.dol.gov/esa/compliance/owcp/ca-5b.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
owcp-5c
Work Capacity Evaluation Form
OWCP-5c.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-5c.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
ca-20
Attending Physicians Report
ca-20.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-20.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
ca-16
Authorization for Examination and/or Treatment
ca-16.pdf
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:
Number of Respondents:
294,540
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
294,540
0
0
-7,945
0
302,485
Annual IC Time Burden (Hours)
30,493
0
0
-255
0
30,748
Annual IC Cost Burden (Dollars)
132,543
0
0
11,543
0
121,000
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.