FECA Medical Report Forms, Claim for compensation
1240-0046
February 2018
Supporting Statement
FECA Medical Report Forms, Claim for Compensation
1240-0046
REVISION
A. Justification.
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.
The Office of Workers' Compensation Programs (OWCP) administers the Federal Employees' Compensation Act (FECA), 5 U.S.C. 8101 et seq. The statute provides for the payment of benefits for wage loss and/or for permanent impairment to a scheduled member, arising out of a work related injury or disease. The Act outlines the elements of pay which are to be included in an individual's pay rate, and sets forth various other criteria for determining eligibility to and the amount of benefits, including: augmentation of basic compensation for individuals with qualifying dependents; a requirement to report any earnings during a period that compensation is claimed; a prohibition against concurrent receipt of FECA benefits and benefits from OPM or certain VA benefits; a mandate that money collected from a liable third party found responsible for the injury for which compensation has been paid is applied to benefits paid or payable. See
http://www.access.gpo.gov/nara/cfr/waisidx_10/20cfr10_10.html
The CA-7 (Claim for Compensation), requests information allowing OWCP to fulfill its statutory requirements for the period of compensation claimed, e.g., the pay rate, dependents, earnings, dual benefits and third party information. The CA-7 is used to claim compensation (20 CFR 10.102). The front page is completed by the claimant. On the back page, the employing agency verifies the accuracy of the claimant's statements and provides relevant information from agency records. If a previous CA-7 claim has been made, only certain sections of the form are completed for subsequent claims.
In the vast majority of cases, compensation is claimed while a claimant continues to be employed by the Federal Government. In those cases, the CA-7 is completed by a Federal employee and their supervisor, therefore not affecting the public, as contemplated under the PRA. See 5 CFR 1320.3(c) (3). The CA-7 is required of a member of the public on rare occasions, such as when compensation is claimed after the claimant's Federal employment has been terminated. It is estimated that no more than 500 of these forms are required of members of the public through the course of a year. This request for clearance by OMB only pertains to a small percentage of the overall use of the CA-7.
The other forms in this clearance collect medical information necessary to determine entitlement to benefits under the FECA. Before compensation may be paid, the case file must contain medical evidence showing that the claimant's disability is causally related to the claimant's federal employment. As a particular claim ages, there is a continuing need for updated information to support continuing benefits. The various forms included in this ICR and the purpose of each are listed below:
CA-16, Authorization for Examination and/or Treatment – is generated by the employing agency, and authorizes the injured employee to seek immediate medical treatment upon sustaining a workplace injury. The form is in two parts; Part A is a completed authorization from the Federal employer; Part B is a medical report (which is further transmitted to OWCP) completed by the physician who first treats the injured employee (20 CFR 10.211, 10.300 and 10.331).
CA-17, Duty Status Report – Part A is completed by the injured worker’s supervisor and referred to the treating physician for completion of Part B. The form is used on a periodic basis, so that an assessment of the employee's condition and ability to perform work can be monitored (20 CFR 10.506).
CA-20, Attending Physician’s Report – The claimant uses this form to obtain medical documentation from the attending physician to support disability (20 CFR 10.331).
CA-1090 refers to a request for the services of an Attendant, in which there is medical documentation from a physician that the claimant requires assistance to care for personal needs such as bathing, dressing, eating, etc. This letter is locally generated from DFEC Correspondence Library, and asks factual information from the claimant and requests that the claimant refer this letter to their treating physician to determine if the claimant is entitled to the services of an attendant (20 CFR 10.314).
CA-1305 is a referral to a medical specialist involving injury to an eye to the extent of claimant's loss of vision. This letter may also be used if the report is being requested from the claimant's current attending physician or from a physician to whom the claimant is being referred for examination by the servicing district office. While this form letter is used very infrequently, it helps claims examiners develop a very difficult issue and is therefore remaining in inventory.
CA-1087, CA-1331 – The CA-1087 specifies OWCP requirements for audiologic examination and is enclosed with the Form CA-1331 when a claimant is referred for a complete audiologic and otologic examination when a claim for hearing loss has been filed.
CA-1332, Outline for Audiologic Examination, is used to obtain a complete report of audiologic and otologic examination. Use of the CA-1332 outline is optional, but when used, it should simplify the process of developing the report for the respondent and result in an improved report.
OWCP-5a, Work Capacity Evaluation, Psychiatric/Psychological Conditions -- Used to obtain the claimant's specific work tolerance limitations where the accepted condition is psychiatric or psychological in nature. It may also be used as an attachment to any original or form letter seeking work limitations.
OWCP-5b, Work Capacity Evaluation, Cardiovascular/Pulmonary Conditions -- Used to obtain claimant's work tolerance limitations where the accepted condition is cardiovascular or pulmonary in nature. It may also be used as an attachment to an original or form letter seeking work limitations.
OWCP-5c, Work Capacity Evaluation, Musculoskeletal Conditions -- Used to obtain the claimant's work tolerance limitations when the accepted condition is musculoskeletal in nature. It may also be attached to any original or form letter which seeks work limitations.
The appropriate sections of the FECA and the implementing Regulations are attached. Authority to collect Social Security Numbers is provided by P.L. 106-113, page 258.
https://www.gpo.gov/fdsys/pkg/PLAW-106publ113/html/PLAW-106publ113.htm
2. Indicate how, by whom, and for what purpose the information is to be used. Except for new collection, indicate the actual use the agency has made of the information received from the current collection.
The information collected by these forms is used by claims examiners for OWCP to determine eligibility for and the computation of benefits. The claim forms, with the medical evidence, are used to determine whether or not the claimant is entitled to compensation for disability for work or permanent impairment of a scheduled member; the appropriate period, rate of pay, compensation rate, any concurrent employment or dual benefits, and third party credit. The OWCP-5 forms are also used by rehabilitation specialists and nurses to assist partially disabled employees to return to suitable employment. Without the requested information, entitlements to an eligible beneficiary could be denied or delayed, or benefits could be authorized at an incorrect rate, resulting in an underpayment or overpayment of compensation.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burdens.
In accordance with the Government Paperwork Elimination Act (GPEA), the Division of Federal Employees’ Compensation seeks to allow individuals and entities that deal with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate.
To improve upon the capabilities for the general public to submit DFEC documents, the agency has an electronic feature that is Internet based, and allows a user to submit non-medical and medical documents such as the CA-7, CA-17, CA-20, and the OWCP-5s electronically to a claim. This application is available to the claimant, employing agency, and the medical provider and there is no cost to the user. See https://www.ecomp.dol.gov/#
When filing a CA-7 electronically, the user will be able to input data to complete their portion of the form that matches the CA-7 paper form. Once data is input, the form can be downloaded and printed, and will appear as the exact same CA-7 form that will appear on the DFEC website. The Department will ask for a non-substantive change in the very near future as the electronic version of the form and the screen shots related to the electronic version of the CA-7 are being finalized.
Over 79,000 documents related to the CA-16, CA-17, CA-20, and the OWCP 5/Work Restriction Forms have been electronically submitted to DFEC during the last clearance cycle, without users incurring any costs. We expect that use of this system as an alternative method will expand in the coming years as a means to reduce costs.
We believe that the implementation of this new system satisfies the requirements of the GPEA to enable the public to electronically filed documents with the Department.
Please note that forms CA-7, CA-17, CA-20, and the OWCP-5s will remain available at the web link below and maybe printed and electronically filled for mail or fax to the appropriate DFEC district office.
http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Forms CA-1090, CA-1305, CA-1331, CA-1332(CA-1087) are all generated solely by the government agency (OWCP) and not the general public.
Form CA-16 is initiated solely by the employing agency and is not available on line for download or electronic submission as it is not a public use form.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.
The information requested on these forms is not duplicative of any information available elsewhere. The claimant, their employer, and their physician are the only sources of the required information. The forms have been streamlined over the years to obtain the necessary medical information while imposing the minimum burden on the respondent. In addition, the information is not collected unless the information is necessary for the adjudication of the case.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
This information collection does not have a significant economic impact on a substantial number of small entities.
6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
If this information was not collected, or was collected less frequently, OWCP would be unable to properly provide disability benefits to injured Federal employees. If benefits were paid in the absence of full information, there would be numerous incorrect payments, creating overpayments, and depriving claimants of benefits to which they are entitled.
7. Explain any special circumstance required in the conduct of the information collection.
Special circumstances which apply to this ICR are as follows:
a. Medical information necessary to determine entitlement to benefits is requested on an as-needed basis. Therefore, respondents often are required to provide information more frequently than quarterly. The need for updating this information is constant. As the medical status of a claimant changes over time, updated medical information must be requested to determine continuing entitlement to compensation.
For example, a claimant who has been paid compensation for specific periods may file a claim for a subsequent period of disability. In order to determine if the claimant is entitled to compensation for that period, the claimant must submit medical documentation pertaining to the period. The OWCP reviews this medical information and uses it to make a decision as to whether or not the claimant is entitled to compensation for the period claimed.
b. Often, medical information is needed from the respondent in less than thirty days. For instance, medical information is needed in order to adjudicate a claim and pay compensation. If the claimant is off work and without income, the prompt submission of the medical needed to support the claim will reduce the financial hardship of the respondent. Also, medical information is needed quickly so that medical treatment and surgeries can be timely authorized and reduce the recovery time of the respondent.
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
While public comments for the 60-day public comment period were welcomed on all the forms and letters associated with this ICR(with significant attention towards the CA-1332 and the CA-16 as noted in item 15), Federal Register Notices inviting comment were published on April 6, 2017 (82FR16858), and on August 3, 2017 (82FR36159). No public comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents, other than payments to contractors.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations or agency policy.
The information collected by these forms is maintained in FECA claim files, which are fully protected under the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1 [77 Fed. Reg. 1728 (Jan. 11, 2012)]. The Privacy Act Statement has been added to the various forms that are associated with this information collection. See http://www.dol.gov/sol/privacy/dol-govt-1.htm.
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
No questions regarding sexual behavior, religious beliefs, etc. are asked. The social security and medical information collected would be considered sensitive, but is essential for proper evaluation of entitlement to benefits. Authority to collect Social Security Numbers is provided by P.L. 106-113, page 258. See
https://www.gpo.gov/fdsys/pkg/PLAW-106publ113/html/PLAW-106publ113.htm
12. Indicate the number of respondents, frequency of response, annual hour burden and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information.
Estimated Annualized Respondent Cost and Burden Hours
FORMS # |
No. of Respondents |
No.of Responses per Respondent |
Total No.of Responses |
Average Burden per Response (in Hrs.) |
Total Hour Burden |
Average Hourly Wage Rate** |
Total Cost Burden |
||
CA-7 |
553 |
1 |
553 |
13/60 |
120 |
$20.59 |
2,471 |
||
MEDICAL REPORT FORMS |
|||||||||
CA-16 |
29,519 |
1 |
29,519 |
5/60 |
2,460 |
$16.78 |
41,279 |
||
CA-17 |
182,793 |
1 |
182,793 |
5/60 |
15,233 |
$16.78 |
255,610 |
||
CA-20 |
56,394 |
1 |
56,394 |
5/60 |
4,700 |
$16.78 |
78,866 |
||
CA-1332 |
11 |
1 |
11 |
30/60 |
6 |
$16.78 |
101 |
||
CA-1090 |
234 |
1 |
234 |
10/60 |
39 |
$16.78 |
654 |
||
CA-1305 |
136 |
1 |
136 |
20/60 |
45 |
$16.78 |
755 |
||
CA-1331/ CA-1087* |
1,062 |
1 |
1,062 |
5/60 |
89 |
$16.78 |
1,493 |
||
OWCP-5s |
11,651 |
1 |
11,651 |
15/60 |
2,913 |
$16.78 |
48,880 |
||
TOTAL |
-- |
|
|
|
282,353 |
-- |
25,605 |
|
$430,109 |
*Responses and hours associated with Form CA-1087 are included in the estimates for the Form CA-1331. The Form CA-1087 is attached to the Form CA-1331.
** http://www.bls.gov/web/empsit/ceseeb8b.htm (for private production workers)
http://www.bls.gov/oes/current/oes430000.htm (for physician staffers)
Burden Hours: Burden hour estimates have been derived from actual respondent usage of these forms/letters. Each estimate represents an average amount of time it takes one respondent to complete one form/letter. For example, in the case of the CA-1332, the burden hours estimate is based as follows: 11 (number of respondents) times 1 (number of responses per respondent) times the average time to complete the letter per response, i.e., (thirty minutes)divided by 60, which equates to 5.5 or 6 burden hours, rounded up.
Burden Costs:
CA-7 Forms:
The burden estimate for the CA-7 Form has increased by 12 hours, from 108 to 120 hours. The cost to the respondent for completing Form CA-7 is determined by using the National Average Hourly Earnings of Private Production Workers – not seasonally adjusted as computed by BLS of $20.59 per hour. The respondent time for the CA-7 is 120 hours for a cost of $2,471.
http://www.bls.gov/web/empsit/ceseeb8b.htm
Medical Forms Only:
Medical report forms are generally completed by administrative support staff based on physician's notes for the signature of the physician. The cost to the respondent on the completion of the medical forms is estimated based upon the mean wage rate of $16.78 (BLS, Occupational Employment and Wages Occupational Code 43-0000 for Office and Administrative Support Occupations, May 2013). The total respondent time for the medical report forms is 25,485 hours, for a cost of $427,638 (25,485 X $16.78).
http://www.bls.gov/oes/current/oes430000.htm
The total respondent cost for medical forms and the CA-7: $427,638 + $2,471 = $430,109.
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
Twenty-five percent of the responses are expected come in via an electronic portal. These respondents are not expected to incur any costs under this item. The remaining percentage will file their documents via mail or fax and incur associated costs.
Number of respondents-electronic means:
282,353 (total number of respondents) x.25 percent (electronic submitted) = 70,588
Number of respondents-mail/fax:
282,353 minus 70,588 = 211,765.
A total of 211,765 responses at $.49 postage + $.03 envelope = $.52 – per response (postage and envelope) = $110,118.
14. Provide estimates of annualized cost to the Federal government.
Federal Cost Estimate:
Review Costs: The average hourly wage for the reviewer is that of a GS-12/6, $38.85 per hour (Federal Salary Table for Rest of US, 2014). These respondents reflect those who submitted documents via mail or via the DFEC web link electronically as noted in item 3.
See http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2014/RUS_h.pdf
Time Total
Form to Review Respondents Cost
CA-7 13 min. 553 $4,655
CA-16 5 min. 29,519 $95,568
CA-17 5 min. 182,793 $591,792
CA-20 5 min. 56,394 $182,576
CA-1090 10 min. 234 $1,515
CA-1305 20 min. 136 $1,761
CA-1331 5 min. 1,062 $3,438
CA-1332 30 min. 11 $214
CA-1087 30 min. 1,062 $20,629
Cost Only
OWCP-5s 15 min. 11,651 $113,160
Total Review Cost $1,015,308
Postage cost: (most of these forms are enclosures or are hand carried to the claimant by the federal employer). It is estimated that approximately 1,000 are mailed each year separately:
1,000 x $.52 = $520.00.
Total Federal Cost: $1,015,828 ($1,015,308 + 520.00 mailing costs)
15. Explain the reasons for any program changes or adjustments.
While several of the forms are being revised, these revisions do not result in any program changes or adjustments. The most significant revision occurred with the CA-16. DFEC is increasing and focusing on program integrity issues, in particular medical billing. As such, the CA-16 has undergone significant changes that are intimately tied to those efforts and we want to incorporate recent and upcoming policy changes. There were other minor changes to the CA-1332, which now gives physicians the opportunity to address tinnitus when assessing impairment. Minor revisions to the CA-1090 were also done. And all the forms/letters now show a revised accommodation statement as a result of comments received from the United States Employment Equal Opportunity Commission (EEOC) in 2015. After consultation with the Department of Labor Civil Rights Center, and the program’Solicitor’s office, an agreement was made on language that would be used in future forms/correspondence. The EEOC was advised that this language would be updated as forms/letter came up for renewal. Attached is a list of all the proposed changes to the form. Attachment 1 contains a summary of the revisions to the specific forms.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
Data collected with these forms will not be published
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
DOL/OWCP/DFEC is not seeking an exemption to display the expiration date on the CA forms.
18. Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods
This information collection does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement |
| Author | US Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |