Supporting Statement

Peace Corps Volunteer Authorization for Examination and/or Treatment

OMB Control Number: 1240-0059

OMB Expiration Date: February 28, 2026

Supporting Statement

Peace Corps Volunteer Authorization for Examination and/or Treatment

1240-0059

This ICR seeks to revision of this information collection.

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 the Office of Personnel Management or certain Department of Veterans Affairs 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.

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. Peace Corps Volunteers are in the performance of duty while abroad during the period of Peace Corps service for purposes of FECA coverage. An injury sustained outside the United States during service is deemed proximately caused by such service, unless the injury or illness was proximately caused by willful misconduct, intention to bring about injury or death, or intoxication.

The Sam Farr and Nick Castle Peace Corps Reform Act of 2018 (Farr-Castle), regulates various aspects of the Peace Corps, including changes to the provision of health care to volunteers. The legislation is named in honor of former Peace Corps volunteers Sam Farr, a retired Democratic congressman, and Nick Castle, who lost his life at age 23 while serving overseas in the Peace Corps in 2013.

The Peace Corps was established on September 22, 1961, by Public Law 87-293, known as the "Peace Corps Act." It authorizes the enrollment of qualified citizens and nationals of the United States as "volunteers" and "volunteer leaders" for service abroad in interested countries and areas, to help the people of such countries and areas in meeting their needs for trained workers, and to help promote a better understanding of the American people on the part of the peoples served and a better understanding of other peoples on the part of the American people.

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). The Secretary may then certify vouchers for these expenses for such volunteers out of the Employees’ Compensation Fund.

OWCP and the Peace Corps collaborated on this form which authorizes 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. This bridges the 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.

References:

https://www.dol.gov/agencies/owcp/FECA/regs/statutes/feca

Sam Farr & Nick Castle Peace Corps Reform Act of 2018, Pub. L. No. 115-256, § 102, 132 Stat. 3650 (2018) (codified as amended at 5 USC § 8142).

https://www.congress.gov/115/plaws/publ256/PLAW-115publ256.pdf

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.

Form CA-15, Peace Corps Volunteer Authorization for Examination and/or Treatment, is the means by which the Peace Corps authorizes initial examination and/or medical treatment at OWCP expense. This form allows treatment for up to 120 days following date of separation from the Peace Corps, a period during which OWCP has a legal obligation to pay for medical services. The form is in two parts; Part A is a completed authorization form from the Peace Corps’ Office of Health Services; Part B is a medical report (which is transmitted to OWCP) completed by the physician who first treats the injured Peace Corps volunteer. Once a case is accepted by OWCP, the period of authorization is automatically extended to cover necessary services for the accepted conditions, and

additional authorization is not necessary unless requested by a provider in a specific case. If a case is denied, however, authorization is revoked for further treatment even though 120 days may have

not elapsed. However, OWCP may approve payment of medical expenses on a case-by-case basis if a Form CA-15 has not been issued, and the claim is subsequently denied.

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.

This form will not be available on the OWCP website for the public to download or for transmission by electronic means to protect against potential fraud and abuse. The form will solely be initiated by a Peace Corps official who is approved to authorize emergency care for recently terminated volunteers. The form CA-15 has 2 parts.  Part A is completed by the employing agency, who is not considered to be part of the public.  Part B is completed by the medical provider, who we consider to be part of the public.  The medical provider mails the completed form along with their bill to the address in item 11 of the form to our medical authorization and billing contractor (CNSI). 

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 this form is not duplicative of any information available elsewhere. The volunteer, the Peace Corps, and their physician are the only sources of the required information. 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, OWCP would be unable to properly provide medical benefits to injured, recently terminated Peace Corps volunteers.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary, trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for the collection of this information.

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. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting public comment was published on XXX.XX,XXXX (XX FR XXXXX). A new Federal Register Notice was published on DATE (XX FR XXXXX). Comments were/were not received. To comply with M-22-10, the individuals/organizations consulted about the information collection are listed in the table below. We have redacted their last names and contact information.

Contact	Organization	Email	Phone
Coby XXX	NALC	XXX	XXX
Kevin XXX	NALC	XXX	XXX
Bob XXX	NFFE	XXX	XXX

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 required 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 [81

Fed. Reg. 47418 (July 21, 2016)]. The Privacy Act Statement has been added to this form 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.

Reference: https://www.gpo.gov/fdsys/pkg/PLAW-106publ113/html/PLAW-106publ113.htm

12. Provide estimates of the hour burden of the collection of information. The statement should:

• 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 conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices. ¹

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

Estimated Annualized Respondent Cost and Hour Burden

Activity	Number of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Annual Burden (Hours)	Hourly Wage Rate*	Monetized Value of Respondent Time
Form CA-15	252	1	252	0.25	63	$23.05	$1,452.00

Burden Hours: Burden hour estimates are derived from estimated actual respondent usage of this form. Each estimate represents an average amount of time it takes one respondent to complete one form. For example, the burden hours estimate is based as follows: 252 (number of respondents) times 1 (number of responses per respondent) times the average time to complete the letter per response, i.e., (fifteen minutes) divided by 60, which equates to 63 burden hours.

Monetized Value of Respondent Times: 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 $23.05 (BLS, Occupational Employment and Wages Occupational Code 43-9199 for Office and Administrative Support Occupations, May 2023). The monetized value of respondent time for the medical report forms is 63 burden hours times hourly wage of $23.05 (63 X $23.05) which equates to $1,452.15 or $1,452.00 (rounded).

The total respondent cost to complete this form is $1,452.00.

Reference: Office and Administrative Support Occupations (bls.gov)

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital and start up cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of service component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with

requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

The cost to respondents for operation and maintenance consists of the price of postage to return the request is $179.00 (252 respondents at $0.71 cents each (postage and envelope).

Respondent Cost

$0.68 (postage) + $0.03 (envelopes) = $ 0.71.

252 X $0.71 = $178.92

Total Cost is $0.71 x 252 = $179.00 rounded

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

Approximately 252 requests are reviewed on an annual basis. The request is reviewed by a Claims Examiner with an average grade GS-12/Step 6, at an hourly rate of $48.61.

Reference: OPM Salary Table 2024 for RUS

Review of this form averages approximately 15 minutes, or 0.25 of an hour. In addition, a mail cost of $0.71 cents (based on postage of $0.68 plus $0.03 cents envelope per response) is associated with mailing a form to a respondent. Computations are noted as follows:

Review Cost: 252 (.25) x $48.61 hr. = $ 3,062.00 rounded

Mailing Cost: 252 x $0.71 = $ 179.00 rounded

Description	Cost ($)
Review Cost	$3,062.00
Mailing Costs	$ 179.00
Annual ECOMP Contract Pricing Hosting	$ 8,550.002
TOTAL	$11,791.00

15. Explain the reasons for any program changes or adjustments

The number of respondents and burden hours remains the same. However, there is a slight increase of annual cost burden from $159.00 to $179.00, a difference of $20.00 mainly due to increase in postage.

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.

There are no plans to publish data collected by this form.

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.

OWCP 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.

1 The FECA retention period for claims is 15 years as noted in the FECA’s record schedule DAA-0271-2017-0003.

2The ECOMP cost is $285,000.00 for FY 2021, 15% or $42,750 of which is dedicated to the maintenance of forms requiring OMB approval. There are 5 forms which require OMB approval which are maintained in ECOMP. These forms are the CA-7, CA-9, CA-15, CA-16, and CA-1032. The ECOMP figure used was based on the average cost for each of those collections, or 1/5 of $42,750, which is $8,550.