OWCP-5a PAGE 2 (Rev. 08-14)
Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation
Act, as amended and extended (5 U.S.C. 8101, et seq.), authorizes collection of this information.
The purpose of this form is to obtain the claimant’s specific work tolerance limitation where the
accepted condition is psychiatric or psychological in nature. Completion of this form is voluntary (5
U.S.C. 8101, et seq), however, failure to provide the information may result in the delay of
processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced
levels of benefits. Additional disclosures of this information may be to: third parties in litigation;
employing agencies, various individuals and organizations providing related medical rehabilitation
and other services; insurance plans which may have paid related bills; labor unions; various law
enforcement officials; other federal, state and local agencies (including the GAO and IRS) as
appropriate; data processing contractors to the Department of Labor; debt collection agencies and
credit bureaus.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this
collection of information unless it displays a currently valid OMB control number. Public reporting
burden for this collection of information is estimated to average 15 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The obligation to respond to
this collection is required to obtain or retain a benefit under 5 U.S.C. 8101, et seq. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers'
Compensation Programs, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210,
and reference the OMB Control Number 1240-0046. Note: Please do not return the requested
information to the address shown just above. Rather, send it to the address shown on the
letterhead.
Notice
Requests for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP in the form
of communication assistance, accommodation(s) and/or modification(s) to aid you in the claims
process. For example, we will provide you with copies of documents in alternate formats,
communication services such as sign language interpretation, or other kinds of adjustments or
changes to accommodate your disability. Please contact our office or your OWCP claims
examiner to ask about this assistance.
