Peace Corps Volunteer Authorization for Examination and/or Treatment

Forms and Documents

Document Name	Status
Form CA-15 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction	Modified
Justification for Non material change. CA15.docx Justification for No Material/Nonsubstantive Change	2022-07-26
Justifiction - CA-15 september 2020.docx Supplementary Document	2020-09-16
Justifiction - CA-15.docx Justification for No Material/Nonsubstantive Change	2020-04-13
1240-0059 Peace Corps Supporting Statement.docx Supporting Statement A	2020-08-20
81 Fed. Reg 47418 (July 21, 2016).pdf Supplementary Document	2020-01-08
2019 OPM Salary Table Cleveland.pdf Supplementary Document	2019-07-15
Office and Administrative Support Workers, All Other May 2018.htm Supplementary Document	2019-07-15
Login page for aqs.html Supplementary Document	2019-07-15
Privacy Act Systems-FECA.docx Supplementary Document	2019-07-15

IC Document Collections

IC ID	Document Title	Status
236890	Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0059	ICR Reference No: 202207-1240-006
Status: Received in OIRA	Previous ICR Reference No: 202008-1240-037
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Peace Corps Volunteer Authorization for Examination and/or Treatment
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/27/2022

	Requested	Previously Approved
Expiration Date	04/30/2023	04/30/2023
Responses	252	252
Time Burden (Hours)	63	63
Cost Burden (Dollars)	146	146

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Abstract: No material/Nonsubstantive Change requested to remove the website reference and update the address on the form. The Sam Farr and Nick Castle Peace Corps Reform Act of 2018 (Farr-Castle), modified various aspects of the Peace Corps, including changes to the provision of health care to volunteers. Under the provisions of the FECA, 5 U.S.C. §8142 of the FECA provides that, (a) For the purpose of this section, "volunteer" means-- (1) a volunteer enrolled in the Peace Corps under section 2504 of title 22; (2) a volunteer leader enrolled in the Peace Corps under section 2505 of title 22; and (3) an applicant for enrollment as a volunteer or volunteer leader during a period of training under section 2507(a) of title 22 before enrollment. Entitlement to disability compensation payments does not commence until the day after the date of termination of service as a volunteer. 5 U.S.C. 8142(b). Farr-Castle directs the Secretary of the Department of Labor to authorize the Director of the Peace Corps to furnish medical benefits to a volunteer, who is injured during the volunteer’s period of service, for a period of 120 days following the termination of such service if the Director certifies that the volunteer’s injury probably meets the requirements set forth in 5 U.S.C. 8142(c)(3). In view of the provisions required by passage of this bill, the Office of Workers’ Compensation Programs (OWCP) and the Peace Corps have collaborated to initiate a new form, CA-15, Peace Corps Volunteer Authorization for Examination and/or Treatment, that will authorize medical treatment for recently terminated Peace Corps volunteers who require medical treatment for injuries/exposure sustained in the performance of their volunteer service. Issuance of this form will solely be at the discretion of the Peace Corps, and will bridge a gap between the occurrence of an initial injury and/or disease exposure and the actual adjudication of a claim by OWCP by helping ensure that recently terminated volunteers receive prompt medical care, without delay, for a period of 120 days following separation from service.

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Authorizing Statute(s): US Code: 5 USC 8101 et.seq Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8142 Name of Law: Peace Corps Volunteers
  

Citations for New Statutory Requirements: US Code: 5 USC 8142 Name of Law: Peace Corps Volunteers
US Code: 5 USC 8101 et.seq Name of Law: Federal Employees' Compensation Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 38671	08/07/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 3424	01/21/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Peace Corps Volunteer Authorization for Examination and/or Treatment	CA-15	Peace Corps Volunteer Authorization for Examination and/or Treatment

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	252	252	0	0	0	0
Annual Time Burden (Hours)	63	63	0	0	0	0
Annual Cost Burden (Dollars)	146	146	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $2,725

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(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 language 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) about:

(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.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/27/2022

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