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Agency Information Collection Activities; Submission for OMB Review; Comment Request; Federal Employees' Compensation Act Medical Report Forms, Claim for Compensation

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Information about this document as published in the Federal Register.

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This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

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On October 31, 2014, the Department of Labor (DOL) will submit the Office of Workers' Compensation Programs (OWCP) sponsored information collection request (ICR) revision titled, “Federal Employees' Compensation Act Medical Report Forms, Claim for Compensation,” to the Office of Management and Budget (OMB) for review and approval for use in accordance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501 et seq.). Public comments on the ICR are invited.


The OMB will consider all written comments that agency receives on or before December 1, 2014.


A copy of this ICR with applicable supporting documentation; including a description of the likely respondents, proposed frequency of response, and estimated total burden may be obtained free of charge from the Web site at​public/​do/​Start Printed Page 64837PRAViewICR?​ref_​nbr=​201406-1240-002 (this link will only become active on November 1, 2014) or by contacting Michel Smyth by telephone at 202-693-4129, TTY 202-693-8064, (these are not toll-free numbers) or sending an email to

Submit comments about this request by mail or courier to the Office of Information and Regulatory Affairs, Attn: OMB Desk Officer for DOL-OWCP, Office of Management and Budget, Room 10235, 725 17th Street NW., Washington, DC 20503; by Fax: 202-395-5806 (this is not a toll-free number); or by email: Commenters are encouraged, but not required, to send a courtesy copy of any comments by mail or courier to the U.S. Department of Labor—OASAM, Office of the Chief Information Officer, Attn: Departmental Information Compliance Management Program, Room N1301, 200 Constitution Avenue NW., Washington, DC 20210; or by email:

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Michel Smyth by telephone at 202-693-4129, TTY 202-693-8064, (these are not toll-free numbers) or sending an email to

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Authority: 44 U.S.C. 3507(a)(1)(D).

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This ICR seeks approval under the PRA for revisions to the Federal Employees' Compensation Act (FECA) medical report forms and claim for compensation information collection requirements. Forms CA-7, CA-16, CA-17, CA-20, CA-1331, CA-1332, OWCP-5A, OWCP-5B, and OWCP-5C 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 FECA. This information collection has been classified as a revision, because of a change to the information collections needed to comply with current Federal law and FECA Bulletin No. 14-01, December 12, 2013. This change impacts augmented compensation, survivor benefits, death gratuity, schedule awards unpaid at death, and other Division of Federal Employees' Compensation administered benefits. Changes are also being made to comply with the Department of Treasury regulations requiring Federal payments to be made via electronic funds transfer instead of by paper checks. In addition, the forms now include an accommodation statement for claimants with mental and/or physical limitations to contact the OWCP if they need further assistance in the claims process. The OWCP has also provided additional guidance to physicians when determining work tolerance limitations to assist in return to work efforts. Finally, the ICR updates reference codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.

This information collection is subject to the PRA. A Federal agency generally cannot conduct or sponsor a collection of information, and the public is generally not required to respond to an information collection, unless it is approved by the OMB under the PRA and displays a currently valid OMB Control Number. In addition, notwithstanding any other provisions of law, no person shall generally be subject to penalty for failing to comply with a collection of information if the collection of information does not display a valid OMB Control Number. See 5 CFR 1320.5(a) and 1320.6. The DOL obtains OMB approval for this information collection under OMB Control Number 1240-0046. The current OMB approval is scheduled to expire on October 31, 2014; however, it should be noted that existing information collection requirements submitted to the OMB receive a month-to-month extension while they undergo review. For additional information, see the related notice published in the Federal Register on July 3, 2014 (79 FR 38072).

Interested parties are encouraged to send comments to the OMB, Office of Information and Regulatory Affairs at the address shown in the ADDRESSES section by December 1, 2014. In order to help ensure appropriate consideration, comments should mention OMB Control Number 1240-0046. The OMB is particularly interested in comments that:

  • 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: DOL-OWCP.

Title of Collection: Federal Employees' Compensation Act Medical Report Forms, Claim for Compensation.

OMB Control Number: 1240-0046.

Affected Public: Individuals or Households.

Total Estimated Number of Respondents: 282,353.

Total Estimated Number of Responses: 282,353.

Total Estimated Annual Time Burden: 25,605 hours.

Total Estimated Annual Other Costs Burden: $110,118.

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Dated: October 27, 2014.

Michel Smyth,

Departmental Clearance Officer.

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[FR Doc. 2014-25895 Filed 10-30-14; 8:45 am]