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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:
1240-0009
ICR Reference No:
201703-1240-006
Status:
Historical Active
Previous ICR Reference No:
201401-1240-001
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Notice of Recurrence
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/03/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/31/2017
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2020
36 Months From Approved
11/30/2017
Responses
289
0
258
Time Burden (Hours)
145
0
129
Cost Burden (Dollars)
150
0
134
Abstract:
This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.
Authorizing Statute(s):
US Code:
5 USC 8101, et seq
Name of Law: Federal Employees' 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:
82 FR 23613
05/23/2017
30-day Notice:
Federal Register Citation:
Citation Date:
82 FR 41306
08/31/2017
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
Notice of Recurrence
CA-2a
Notice of Recurrence
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
289
258
0
0
31
0
Annual Time Burden (Hours)
145
129
0
0
16
0
Annual Cost Burden (Dollars)
150
134
0
0
16
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:
The adjustment for this submission is due to an increase in the number of claims since the last approval. Over the last three calendar (CY2014-2016) an average of 5,770 recurrences were submitted, an increase of 608 claims per year (5,162 was the average figure in the previous ICR submission in 2014). In applying the 5% rule described in the discussion in section A.1 above towards the number of claims being submitted by claimants who have left federal employment, the number of claims submitted by this group during this period is 289 (5% x 5,770). This figure represents an increase of 31 claims since the last OMB submission, 258 (5% of 5,162 ) The requested annual cost burden in dollars is $150 (.52 x 289), which is an increase of $16.00 from the previous submission of $134 (.52 x 258).
Annual Cost to Federal Government:
$5,313
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
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:
08/31/2017
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