This form is used by current, or
occasionally former, Federal employees to claim wage loss or
medical treatment resulting from a recurrence of a work-related
injury while Federally employed. The information is necessary to
ensure the accurate payment of benefits.
US Code:
5 USC 8101, et seq Name of Law: Federal Employees' Compensation
Act
There is a decrease of 28 in
the number of claims being submitted by claimants who have left
federal employment, which results in a burden hour reduction of
-14.
$10,410
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Carol Adams 904 357-4747 ext.
74105
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:
(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;
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.