OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Notice of Peace Corps Volunteer Authorization for Examination and/or Treatment

ICR 202505-1240-004 · OMB 1240-0059 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form CA-15 Peace Corps Volunteer Authorization for Examination And/Or Treatment Form and Instruction Modified Repair queued
Form CA-15 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction Modified Repair queued
Supporting Statement for 1240-0059 Peace Corps Volunteer Auth for Exam and or Treatment (CA-15) - 11-19-2025.docx Supporting Statement A Uploaded 2025-11-20 Repair queued
Supporting Statement for 1240-0059 Peace Corps Volunteer Auth for Exam and or Treatment (CA-15) OCIO1.clean copy.docx Supporting Statement A Uploaded 2025-09-25 Available
Privacy Act Systems-FECA.docx Supplementary Document Uploaded 2025-05-28 Repair queued
Privacy Act Systems-FECA.docx Supplementary Document Uploaded 2025-05-28 Repair queued
BLS Occupational Employment and Wages.html Supplementary Document Uploaded 2025-05-28 Repair queued
BLS Occupational Employment and Wages.html Supplementary Document Uploaded 2025-05-28 Available
OPM Salary Table - RUS.pdf Supplementary Document Uploaded 2025-05-28 Available
OPM Salary Table - RUS.pdf Supplementary Document Uploaded 2025-05-28 Repair queued
Agency AQS.html Supplementary Document Uploaded 2025-05-28 Repair queued
Agency AQS.html Supplementary Document Uploaded 2025-05-28 Repair queued
DOL GOVT-1.docx Supplementary Document Uploaded 2025-05-28 Repair queued
DOL GOVT-1.docx Supplementary Document Uploaded 2025-05-28 Available
IC Document Collections
IC IDCollectionTypeStatusForm
236890 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction ModifiedPeace Corps Volunteer Authorization for Examination And/Or Treatment
236890 Peace Corps Volunteer Authorization for Examination and/or Treatment Form and Instruction Modified
ICR Details
1240-0059 202505-1240-004
Active 202212-1240-002
DOL/OWCP
Notice of Peace Corps Volunteer Authorization for Examination and/or Treatment
Extension without change of a currently approved collection   No
Regular
Approved with change 12/15/2025
Retrieve Notice of Action (NOA) 11/13/2025
  Inventory as of this Action Requested Previously Approved
12/31/2028 36 Months From Approved 02/28/2026
48 0 252
12 0 63
10 0 159
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. DOL 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.
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 8101 et.seq Name of Law: Federal Employees' Compensation Act
US Code: 5 USC 8142 Name of Law: Peace Corps Volunteers
Not associated with rulemaking
  90 FR 23962 06/05/2025
90 FR 47343 10/01/2025
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 48 252 0 -204 0 0
Annual Time Burden (Hours) 12 63 0 -51 0 0
Annual Cost Burden (Dollars) 10 159 0 -149 0 0
No
Yes
Miscellaneous Actions
The previously approved number of respondents for FECA has decreased from 252 to 48 respondents and responses, which is a difference of 204. We attribute this decrease to a more efficient tracking system that allowed us to effectively screen duplicate and/or inaccurate submissions.
$8,786
No
    No
    Yes
No
No
No
No
Ebony Henry 212 863-0831 [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.
11/13/2025