View Information Collection Request (ICR) Package

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: 201805-1240-007
Status: Historical Active	Previous ICR Reference No: 201503-1240-001
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 without change	Conclusion Date: 02/14/2019
	Date Received in OIRA: 11/30/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2022	36 Months From Approved	02/28/2019
Responses	3,452	0	3,752
Time Burden (Hours)	575	0	625
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	3,452	3,752	-300
Annual Time Burden (Hours)	575	625	-50
Annual Cost Burden (Dollars)	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: It is noted that there has been a slight change in the number of forms filed annually since the last OMB submission from 2015. The responses from the respondents decreased from 3,752 to 3,452. Accordingly, the burden hours decreased from 625 to 575 an adjustment of 50 hours. Minor revision to the form is noted below: Added a line/space to the OWCP Rehabilitation Specialist or Rehabilitation Counselor section to clarify who is required to sign the form. Changed the font in the fillable sections to improve readability.

Annual Cost to Federal Government: $85,020

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

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