Type of Review: New Collection.
Agency: Employment Standards Administration.
Title: Claimant Medical Reimbursement Form (CA-915).
OMB Number: 1215-0193.
Affected Public: Individuals or households, Federal Government.
Total Respondents: 40,500.
Frequency: On occasion.
Total Responses: 40,500.
Average Time per Response: 10 minutes.
Total Hours: 6,723.
Total Burden Cost (capital/startup): 0.
Total Burden Cost (operating/maintenance): 0.
Type of Review: New Collection.
Agency: Employment Standards Administration.
Title: NCPDP Universal Pharmacy Billing Form (79-1A) .
OMB Number: 1215-0194.
ffected Public: Businesses or other for-profit; Not-for-profit
Institutions; Individuals or households; Federal Government; State,
Local or Tribal Government.
Total Respondents: 406,198.
Frequency: On occasion.
Total Responses: 406,198.
Average Time per Response: 5 minutes.
Total Hours: 33,714.
Total Burden Cost (capital/startup): 0.
Total Burden Cost (operating/maintenance): 0.
Affected Public: Businesses or other for-profit; Not-for-profit
Institutions; Individuals or households; Federal Government; State,
Local or Tribal Government.
Total Respondents: 406,198.
Frequency: On occasion.
Total Responses: 406,198.
Average Time per Response: 5 minutes.
Total Hours: 33,714.
Total Burden Cost (capital/startup): 0.
Total Burden Cost (operating/maintenance): 0.

Section 10.104(a)-(new traumatic injuries, new occupational diseases, and new events contributing to already-existing occupational diseases).

Section 10.104(b)

An agency asked whether the statement accompanying Form CA-2a is to be submitted as a separate narrative, since the information listed in this paragraph is also listed on Form CA-2a. The paragraph is being reworded so that it refers to the specific requirements stated on Form CA-2a, just as Sec. 10.104(b)(2) refers to specific requirements stated on Form CA-2a with reference to the submittal of a medical report.

CA2A-Section 10.105(a)

A labor organization suggested that this section be reworded to refer to the claimant as the ``survivor claimant'' throughout. As the referent changes from ``survivor'' to ``claimant'' in the middle of the paragraph, different wording would clearly be desirable. Therefore, ``claimant'' has been changed to ``survivor'' both in this paragraph and in paragraph (c). SSNs are to be provided for all survivors on whose behalf benefits are being claimed .

CA2A-Section 10.105(d)

A labor organization suggested that the first sentence of this paragraph, which parallels the language of section 8122(c), be expanded to include occupational diseases, and this change has been made.

CA-3

Three agencies commented on the use of Form CA-3, two stating that they would like to see continued use of the form, and one stating thatthere should be some way to report return to duty in its place. If the form is not to be required, one agency said that it should be removed from the list. On balance, OWCP does not believe that use of the form should be required, since agencies routinely notify the district offices when employees return to work. Form CA-3 is therefore being removed from the list. However, OWCP is looking into alternative means of collecting the information requested on this form.

CA-7

One agency suggested that this section be amended to include a statement that Form CA-7 is not needed during the initial period of disability, which is covered by COP. The first sentence is being modified to clarify this point.

Sec. 10.103 How and when is a claim for permanent impairment filed?

Form CA-7 is used to claim compensation for impairment to a body part covered under the schedule established by 5 U.S.C. 8107. If Form CA-7 has already been filed to claim disability compensation, an employee may file a claim for such impairment by sending a letter toOWCP which specifies the nature of the benefit claimed.

CA-12

One agency inquired about the purpose of Form CA-12, and another suggested that it simply be deleted from the list. A labor organization suggested that its purpose be clarified. OWCP uses this form to obtain reports of dependents in death cases. As the form is used exclusively by OWCP, and employers have no need to stock it, it is being removed from the list.

CA-16

Three labor organizations argued that the proposed rule limiting issuance of Form CA-16 to one week following the injury is inconsistent with the statutory 30-day requirement for claiming COP.

Still another labor organization stated that changing to a one-week limit from what it considered to be the current time frame of six months from the date of injury to be ``radical and inappropriate''. OWCP does not agree. The purpose of Form CA-16 is to authorize urgently-needed medical care in connection with a work-related traumatic injury, not to provide blanket medical coverage. An employee whose need for medical care develops so gradually that it is not apparent until a week after the injury occurred cannot accurately be said to require urgent medical care. The time requirements for claiming COP have no relation to those governing issuance of Form CA-16.Sec. 10.300 What are the basic rules for authorizing emergency medical care?

(a) When an employee sustains a work-related traumatic injury that requires medical examination, medical treatment, or both, the employer shall authorize such examination and/or treatment by issuing a Form CA-

16. This form may be used for occupational disease or illness only if the employer has obtained prior permission from OWCP.

(b) The employer shall issue Form CA-16 within four hours of the claimed injury. If the employer gives verbal authorization for such care, he or she should issue a Form CA-16 within 48 hours. The employer is not required to issue a Form CA-16 more than one week after the occurrence of the claimed injury. The employer may not authorize examination or medical or other treatment in any case that OWCP has disallowed.

(c) Form CA-16 must contain the full name and address of the qualified physician or qualified medical facility authorized to provide service. The authorizing official must sign and date the form and must state his or her title. Form CA-16 authorizes treatment for 60 days from the date of issuance, unless OWCP terminates the authorization sooner.

(d) The employer should advise the employee of the right to his or her initial choice of physician. The employer shall allow the employee to select a qualified physician, after advising him or her of those physicians excluded under subpart I of this part. The physician may be in private practice, including a health maintenance organization (HMO), or employed by a Federal agency such as the Department of the Army, Navy, Air Force, or Veterans Affairs. Any qualified physician may provide initial treatment of a work-related injury in an emergency. See also Sec. 10.825(b).

CA-17

Another issue is whether Form CA-17 may be used only for traumatic injuries. One agency notes that it might well be used to determine work limitations in certain kinds of occupational illness cases. OWCP concurs, and the word ``traumatic'' has been removed from this paragraph.

A labor organization asked whether it is appropriate to use Form CA-17 for occupational diseases as well as traumatic injuries. OWCP has revised Sec. 10.331(b) to allow its use in both kinds of situations

Claim filing

Section 10.205(a)(2)

An employing agency inquired as to what would constitute ``another form'' acceptable to OWCP, and whether a letter would suffice. This language is included so that the regulations reflect OWCP's position that a Form CA-2, CA-7 or CA-8 (all of which contain words of claim) fulfills the requirement that notice be given ``in writing'' under the appropriate circumstances. The word ``form'' does in fact denote an OWCP-approved claim form, and a letter would not serve the purpose.

Sec. 10.110 What should the employer do when an employee files a notice of traumatic injury or occupational disease?

(a) The employer shall complete the agency portion of Form CA-1 (for traumatic injury) or CA-2 (for occupational disease) no more than 10 working days after receipt of notice from the employee. The employer shall also complete the Receipt of Notice and give it to the employee, along with copies of both sides of Form CA-1 or Form CA-2.

Forms (modifying)

Two employee organizations suggested that this section include a statement that employers may not modify forms prescribed by OWCP, or use substitute forms. A statement to that effect is being added to paragraph (a).