View Information Collection Request (ICR) Package
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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:
1240-0059
ICR Reference No:
202405-1240-004
Status:
Historical Inactive
Previous ICR Reference No:
202212-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Peace Corps Volunteer Authorization for Examination and/or Treatment
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Withdrawn and continue
Conclusion Date:
08/26/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/06/2025
Terms of Clearance:
Withdrawn at the request of DOL.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/28/2026
36 Months From Approved
02/28/2026
Responses
252
0
252
Time Burden (Hours)
63
0
63
Cost Burden (Dollars)
159
0
159
Abstract:
OWCP administers the Federal Employees' Compensation Act (FECA). A Peace Corps Volunteer who sustains an injury or contracts an illness overseas while in Peace Corps service may be entitled to benefits under the FECA. The Department of Labor authorizes the Peace Corps to furnish medical benefits to a volunteer, who is injured during the volunteer’s period of service, for a period of 120 days following termination if the service volunteer’s injury meets requirements.
Authorizing Statute(s):
US Code:
5 USC 8142
Name of Law: Peace Corps Volunteers
US Code:
5 USC 8101 et.seq
Name of Law: Federal Employees' Compensation Act
Citations for New Statutory Requirements:
US Code: 5 USC 8101 et.seq Name of Law: Federal Employees' Compensation Act
US Code: 5 USC 8142 Name of Law: Peace Corps Volunteers
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:
89 FR 51908
06/20/2024
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 37889
08/06/2025
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
Peace Corps Volunteer Authorization for Examination and/or Treatment
CA-15
Peace Corps Volunteer Authorization for Examination And/Or Treatment
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:
Annual Cost to Federal Government:
$11,457
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.
No
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
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:
08/06/2025
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