View Information Collection Request (ICR) Package
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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:
1240-0001
ICR Reference No:
201504-1240-001
Status:
Historical Active
Previous ICR Reference No:
201202-1240-002
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Statement of Recovery Forms
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:
11/25/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/07/2015
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2018
36 Months From Approved
11/30/2015
Responses
842
0
2,832
Time Burden (Hours)
419
0
1,346
Cost Burden (Dollars)
219
0
1,360
Abstract:
These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.
Authorizing Statute(s):
US Code:
5 USC 8132
Name of Law: Federal Employees' Compensation Act
US Code:
5 USC 8131
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:
80 FR 26955
05/11/2015
30-day Notice:
Federal Register Citation:
Citation Date:
80 FR 47527
08/07/2015
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Statement of Recovery
ca-1122
Statement of Recovery
Statement of Recovery Forms
ca-1108
Statement of Recovery
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
842
2,832
0
0
-1,990
0
Annual Time Burden (Hours)
419
1,346
0
0
-927
0
Annual Cost Burden (Dollars)
219
1,360
0
0
-1,141
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 previous approved number of annual responses, 2,832 is being reduced to 842, which represent a reduction of 1,990. The currently approved number of hours is 1,346 and the requested number of hours is 419, a decrease of 927. Likewise, costs burden is now estimated at $219 versus the previously approved $1,360, which represents a decrease of $1,141. Decrease in these numbers is suggested as a result of SOL implementing a more accurate system for monitoring all third-party matters, resulting in a more accurate method of estimating the number of respondents. Additionally, as SOL and respondents are using electronic means, costs associated with mailing have reduced approximately 50 percent. Summary of revisions to these letters are the following: CA-1108 – • The letter has been expanded to automatically calculate attorney fee/court costs when data is entered into items 9 and 11. • A statement was added on page one of the form to advise beneficiaries of their net entitlement of money/property remaining after expenses of a suit/settlement has been settled. • The Instructions were expanded in Lines 9 and 11 to include a statement regarding calculations of attorney fee/court costs. • At the bottom of the Instructions, the OWCP File Number is requested if there is a refund as noted in Line 18. CA-1122 - • Spacing for the OWCP Case Number and Employee Name have been added. • At the bottom of the Instructions, the OWCP File Number is requested if there is a refund as noted in Line 9.
Annual Cost to Federal Government:
$12,032
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:
08/07/2015
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