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
OMB 1240-0059 Peace Corps Supporting Statement 2025 Early Rev.docx Supporting Statement A	2025-08-01
60 day FRN 1240-0059. published.pdf Supplementary Document	2024-09-09
81 Fed. Reg 47418 (July 21, 2016).pdf Supplementary Document	2022-12-23
Privacy Act Systems-FECA.docx Supplementary Document	2022-12-23

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: 202405-1240-004
Status: Received in OIRA	Previous ICR Reference No: 202212-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Peace Corps Volunteer Authorization for Examination and/or Treatment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/06/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2026
Responses	252	252
Time Burden (Hours)	63	63
Cost Burden (Dollars)	252	159

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Abstract: OWCP administers the Federal Employees' Compensation Act (FECA). A Peace Corps Volunteer who sustains an injury or contracts an illness overseas while in Peace Corps service may be entitled to benefits under the FECA. The Department of Labor authorizes 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 termination if the service volunteer’s injury meets requirements.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: 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

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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:
	89 FR 51908	06/20/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 37889	08/06/2025
Did the Agency receive public comments on this ICR? No

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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)	252	159	0	93	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:

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Annual Cost to Federal Government: $11,457

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: 08/06/2025

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