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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1240-0012
ICR Reference No:
201503-1240-001
Status:
Historical Active
Previous ICR Reference No:
201112-1240-001
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Rehabilitation Maintenance Certificate
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
11/25/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/23/2015
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2018
36 Months From Approved
11/30/2015
Responses
3,752
0
5,022
Time Burden (Hours)
625
0
837
Cost Burden (Dollars)
0
0
0
Abstract:
Form OWCP-17 serves as a bill submitted by the program participant or OWCP, requesting reimbursement of expenses incurred due to participation in an approved rehabilitation effort for the preceding four-week period of fraction thereof.
Authorizing Statute(s):
US Code:
5 USC 8111
Name of Law: Federal Employees’ Compensation Act
US Code:
5 USC 8121
Name of Law: Federal Employees’ Compensation Act
US Code:
33 USC 939
Name of Law: Longshore and Harbor Workers’ Compensation Act
US Code:
33 USC 908(g)
Name of Law: Longshore and Harbor Workers’ Compensation Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
80 FR 23823
04/29/2015
30-day Notice:
Federal Register Citation:
Citation Date:
80 FR 43795
07/23/2015
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Rehabilitation Maintenance Certificate
OWCP-17
Rehabilitation Maintenance Certificate
ICR Summary of Burden
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
3,752
5,022
0
0
-1,270
0
Annual Time Burden (Hours)
625
837
0
0
-212
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Since the last clearance three years ago, the responses from the respondents decreased from 5,022 to 3,752, which is an adjustment of 1,270 responses. Accordingly, the burden hours decreased from 837 to 625, an adjustment of 212 hours. Summary of revisions to this form includes the following: Several minor changes were made to the form to enhance record-keeping and ease of use as well as to reflect current administrative practices. The space for Injured Worker address was moved from mid-page to the top of the page under the Injured Worker's name for organizational purposes. A "Weekly Training Schedule" section was added to further document the Injured Workers training or educational schedule and to assist with proper payment of maintenance funds. Finally, under "Please Read Carefully," instructions were adjusted to reflect the agency's transition to use of forms in digital format, rather than carbon copies, as well as to more accurately reflect the current administrative practice of Rehabilitation Counselors, rather than Specialists, completing the initial form review. These adjustments will not change the overall administrative function of the form and will not increase user burden.
Annual Cost to Federal Government:
$92,082
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
07/23/2015
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