Paperwork Reduction Act Submission

PAPERWORK REDUCTION ACT SUBMISSION

Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork Clearance Officer, Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street N.W. Washington, D.C. 20503.
1. Agency/Subagency originating request USDOL/ESA/OWCP/DFEC	2. OMB control number b. |___| None a. 1215 - 0103
3. Type of information collection (check one) a. | | New collection b. | | Revision of currently approved collection c. | X| Extension of a currently approved collection d. | | Reinstatement, without change, of a previously approved collection for which approval has expired e. | | Reinstatement, with change, of a previously approved collection for which approval has expired f. | | Existing collection in use without an OMB control number For b-f, note item A2 of Supporting Statement	4. Type of review requested (check one) a. |X | Regular b. | | Emergency - Approval requested by: / / c. | | Delegated 5. Small entities Will this information collection have a significant economic impact on a substantial number of small entities? | | Yes | X | No 6. Requested expiration date a. | X | Three years from approval date b.| | Other Specify: /
7. Title FECA Medical Report Forms and Claim for Compensation CA-7, CA-16, CA-17, CA-20, CA-1087, CA-1090, CA-1303, CA-1305, CA-1331, CA-1332, QCM-Letters, OWCP-5A, OWCP-5B and OWCP-5c
7. Title CA-7, CA-16, CA-17, CA-20, CA-1087, CA-1090, CA-1303, CA-1305, CA-1331, CA-1332, QCM-Letters, OWCP-5A, OWCP-5B and OWCP-5c
9. Keywords Beneficiaries; compensation claims; medical records
10. Abstract 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 (FECA), 5 USC 8101 et. seq.
11. Affected public (Mark primary with "P" and all others that apply with "X") a. X Individuals or households d. Farms b. P Business or other for-profit e. X Federal Government c. Not-for-profit institutions f. State, Local or Tribal Government	12. Obligation to respond (Mark primary with "P" and all others that apply with "X") a Voluntary b. P Required to obtain or retain benefits c. Mandatory
13. Annual reporting and recordkeeping hour burden a. Number of respondents 294540 b. Total annual responses 294540 1. Percentages of these responses collected electronically 0 % c. Total annual hours requested 30493 d. Current OMB inventory 30,748 e. Difference (255) f. Explanation of difference 1. Program change 2. Adjustment (255)	14. Annual reporting and recordkeeping cost burden (in thousands of dollars) a. Total annualized capital/startup costs b. Total annual costs (O&M) 133 c. Total annualized cost requested 133 d. Current OMB inventory 121 e. Difference 12 f. Explanation of difference 1. Program change 2. Adjustment 12
15. Purpose of information collection (Mark primary with "P" and all others that apply with "X") a. P Application for benefits e. Program planning or management b. Program evaluation f. Research c. General purpose statistics g. Regulatory or compliance d. Audit	16. Frequency of recordkeeping or reporting (check all that apply) a. | | Recordkeeping b. | | Third party disclosure c. | X| Reporting 1. | | On occasion 2. | | Weekly 3. | | Monthly 4. | | Quarterly 5. | | Semi-annually 6. | | Annually 7. | | Biennially 8. | X | Other (describe)
17. Statistical methods Does this information collection employ statistical methods? | | Yes | X | No	18. Agency contact (Person who can best answer questions regarding the content of this submission) Name: CAROL E. ADAMS Phone: (904)357-4789 EXT 74105

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19. Certification for Paperwork Reduction Act Submissions On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9. NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8 (b)(3), appear at the end of the instructions. The certification is to be made with reference to those regulatory provisions as set forth in the instructions. 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 terminology 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); (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 (see note in Item 19 of the instructions); (i) It uses effective and efficient statistical survey methodology; and, (j) It makes appropriate use of information technology. If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in Item 18 of the Supporting Statement.
Signature of Agency Official	Date
Signature of Senior Official or designee	Date

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