OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Peace Corps Volunteer Authorization for Examination and/or Treatment

ICR 202207-1240-006 · OMB 1240-0059 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CA-15 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction Modified Repair queued
Justification for Non material change. CA15.docx Justification for No Material/Nonsubstantive Change Uploaded 2022-07-26 Repair queued
Justifiction - CA-15 september 2020.docx Supplementary Document Uploaded 2020-09-16 Repair queued
Justifiction - CA-15.docx Justification for No Material/Nonsubstantive Change Uploaded 2020-04-13 Repair queued
1240-0059 Peace Corps Supporting Statement.docx Supporting Statement A Uploaded 2020-08-20 Repair queued
81 Fed. Reg 47418 (July 21, 2016).pdf Supplementary Document Uploaded 2020-01-08 Repair queued
2019 OPM Salary Table Cleveland.pdf Supplementary Document Uploaded 2019-07-15 Repair queued
Office and Administrative Support Workers, All Other May 2018.htm Supplementary Document Uploaded 2019-07-15 Repair queued
Login page for aqs.html Supplementary Document Uploaded 2019-07-15 Repair queued
Privacy Act Systems-FECA.docx Supplementary Document Uploaded 2019-07-15 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
236890 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction Modified
ICR Details
1240-0059 202207-1240-006
Received in OIRA 202008-1240-037
DOL/OWCP
Peace Corps Volunteer Authorization for Examination and/or Treatment
No material or nonsubstantive change to a currently approved collection   No
Regular 07/27/2022
  Requested Previously Approved
04/30/2023 04/30/2023
252 252
63 63
146 146
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.
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
  
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
Not associated with rulemaking
  84 FR 38671 08/07/2019
85 FR 3424 01/21/2020
Yes
  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
No
No
This is a new collection.
$2,725
No
    No
    Yes
No
No
No
No
Marcus Sharpless 202 693-0998 [email protected]
  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.
07/27/2022