The Department of Labor (DOL) has submitted the following public information collection request (ICR) to the Office of Management and Budget (OMB) for review and approval in accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13, 44 U.S.C. chapter 35). A copy of this ICR, with applicable supporting documentation, may be obtained by contacting Darrin King on 202-693-4129 (this is not a toll-free number) or e-mail: email@example.com.
Comments should be sent to Office of Information and Regulatory Affairs, Attn: OMB Desk Officer for the Employment Standards Administration (ESA), Office of Management and Budget, Room 10235, Washington, DC 20503, 202-395-7316 (this is not a toll-free number), within 30 days from the date of this publication in the Federal Register.
The OMB is particularly interested in comments which:
- Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility;
- Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used;
- Enhance the quality, utility, and clarity of the information to be collected; and
- Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.
Agency: Employment Standards Administration.
Type of Review: Extension of currently approved collection.
Title: FECA Medical Report Forms, Claim for Compensation.
OMB Number: 1215-0103.
Frequency: As needed and annually.
Type of Response: Reporting.
Affected Public: Individuals or households; business or other for-profit; and Federal government.
Number of Respondents: 287,660.
|Form No.||Estimated annual responses||Average response time (hours)||Estimated annual burden hours|
|CA-1331 / CA-1087||250||0.08||21|
|*Quality Case Management|
Total Annualized capital/startup costs: $0.
Total Annual Costs (operating/maintaining systems or purchasing services): $120,994.
Description: 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, 5 U.S.C. 8101 et seq.Start Signature
Ira L. Mills,
Departmental Clearance Officer.
[FR Doc. 05-13417 Filed 7-7-05; 8:45 am]
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