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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:
1240-0021
ICR Reference No:
201207-1240-004
Status:
Historical Active
Previous ICR Reference No:
201003-1240-021
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Provider Enrollment Form
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:
01/08/2013
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/07/2012
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2016
36 Months From Approved
01/31/2013
Responses
53,934
0
70,185
Time Burden (Hours)
7,174
0
9,335
Cost Burden (Dollars)
25,888
0
32,987
Abstract:
Form OWCP-1168 requests profile information on providers that enroll in one (or more) of OWCP's benefit programs so its billing contractor can pay them for services rendered to beneficiaries using its automated bill processing system.
Authorizing Statute(s):
US Code:
30 USC 901
Name of Law: The Black Lung Benefits Act (BLBA)
US Code:
5 USC 8101
Name of Law: The Federal Employees' Compensation Act (FECA)
US Code:
42 USC 7384
Name of Law: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
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:
77 FR 43126
07/23/2012
30-day Notice:
Federal Register Citation:
Citation Date:
77 FR 66869
11/07/2012
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
Provider Enrollment Form
OWCP-1168, OWCP-1168 Web version screen shots
Provider Enrollment Form
,
Provider Enrollment For, Screen Shots
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
53,934
70,185
0
0
-16,251
0
Annual Time Burden (Hours)
7,174
9,335
0
0
-2,161
0
Annual Cost Burden (Dollars)
25,888
32,987
0
0
-7,099
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:
There has been a decrease in the number of respondents seeking to provide medical or vocational services to beneficiaries. There is an adjustment of -2,161 in burden hours and -$7,099 in operational and maintenance costs. While not expected to change respondent burden, this ICR has been characterized as a revision because the agency has reformatted elements of Form OWCP-1168 (e.g., replaced an obsolete logo with the DOL Seal, OMB Control Number, additional notice on rights for persons with disabilities, and removed references to the no longer existent Employment Standards Administration). Upon OMB's clearance of this request OWCP will update the form to show the new expiration date.
Annual Cost to Federal Government:
$1,507,455
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:
Yoon Ferguson 202 693-0701 ferguson.yoon@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:
11/07/2012
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