Summary of Revisons

SUMMARY OF REVISIONS TO CA-1032

EXPIRATION 2/28/2011

ICR 1240-0016, FORMERLY 1215-0151

1^st page:

• 1^st paragraph. After second sentence, added the following sentence: Accordingly, you must report to OWCP any improvement in your medical condition, any employment, any change in the status of claimed dependents, any third party settlement, and any income or change in income from Federally assisted disability or benefit programs.

• 3^rd sentence, Under Warning, added “also” between “may” and “result”

4^th sentence, added the following statement, “OR CIVIL ACTION FOR FALSE CLAIMS.”

3^rd Page:

Revised the Public Burden and Privacy Act Statements as follows:

The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine continuing entitlement to benefits. Furnishing the requested information is required for the claimant to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C. 552a). Failure to furnish the requested information may delay the process, or result in an unfavorable decision or a reduced benefit.

PUBLIC BURDEN STATEMENT

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send them to the Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

PRIVACY ACT STATEMENT

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S .Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations

PRIVACY ACT STATEMENT (Cont’d)

for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) on this form is mandatory. The SSN, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

4^th Page, Part A—Employment

• 4^th line, after “affiliates” added, the following sentence, “ Please note that you must report any employment held at the time of injury if you have worked at that employment during any period covered by this form.”

• Under the paragraph, Report ANY work or ownership interest in any business enterprise,

Last sentence, added “or passive investment” between “ownership” and “in”.

• Added the following sentence after the above revision. “ If you have questions about whether something is material or relevant and should be included, please list that information. “

5^th page, Part B, Volunteer Work,

• 1^st sentence, added “including volunteer work” between “work” and “for”

• Last sentence, added after “did”, “and include a description of that work”:

6^th page, Part C—Dependents

• 2d paragraph, 1^st sentence, added “augmented” between “claim” and “compensation”

• 3^rd paragraph, last sentence, after support, added, “YOU MAY NOT CLAIM OR RECEIVE AUGMENTED COMPENSATION FOR AN EX-SPOUSE EVEN IF YOU HAVE BEEN ORDERED TO PROVIDE SUPPORT IN THE FORM OF ALIMONY. “

7^th page, Part C—Dependents (Continued)

• #3. 1^st sentence, added, “You are required to report any changes in dependents as soon as those changes occur.”

8^th Page, Part E--Third Party,

• after 1^st sentence, added ,”This includes any product liability or medical malpractice settlement/award you have received that relates to treatment for your accepted injury or illness. Yes or No: ______”

8^th page, Part H—Certification,

• After 4^th sentence, added, “I know that fraudulently concealing or failing to report income or other information in claiming payment or benefit under FECA may result in the forfeiture of compensation for the period covered by this form and may also result in a civil action against me for damages under the False Claims Act or other applicable laws.”

• In second paragraph, revised as, “I understand that I must immediately report to OWCP any employment or employment activity, any change in the status of claimed dependents, any third party settlement, and any monies or income or change in monies or income from Federally assisted disability or benefit programs.”

All Pages

• Added OMB No: and Expiration Date

• Revised Form No/Expiration Dates and Page Numbers

• Noted Revision Date as August 2010

Note: The form was reviewed by the Solicitor’s Office and the Branch Chief, Policy and Procedures.

MARCUS J. SHARPLESS