Federal Employees' Compensation Act Medical Reports and Compensation Claims

ICR 202407-1240-001

OMB: 1240-0046

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2024-07-18
Justification for No Material/Nonsubstantive Change
2024-07-18
Supplementary Document
2023-03-20
Supplementary Document
2023-03-20
Supplementary Document
2023-03-20
Supplementary Document
2023-03-20
Supporting Statement A
2023-06-06
Supporting Statement A
2023-06-06
Supplementary Document
2023-03-20
Supplementary Document
2023-03-20
Supplementary Document
2023-03-20
Supplementary Document
2023-03-20
ICR Details
1240-0046 202407-1240-001
Active 202303-1240-001
DOL/OWCP
Federal Employees' Compensation Act Medical Reports and Compensation Claims
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 08/26/2024
Retrieve Notice of Action (NOA) 08/20/2024
  Inventory as of this Action Requested Previously Approved
08/31/2026 08/31/2026 08/31/2026
282,353 0 282,353
25,605 0 25,605
133,412 0 133,412

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).

US Code: 5 USC 8149 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8101 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8102 Name of Law: Federal Employees Compensation Act
   US Code: 5 USC 8103 Name of Law: Federal Employees Compensation Act
  
None

Not associated with rulemaking

  88 FR 16038 03/15/2023
88 FR 44156 07/11/2023
No

  Total Approved 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 282,353 282,353 0 0 0 0
Annual Time Burden (Hours) 25,605 25,605 0 0 0 0
Annual Cost Burden (Dollars) 133,412 133,412 0 0 0 0
No
No

$1,218,781
No
    Yes
    Yes
No
No
No
No
Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/20/2024


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