View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 1240-0020	ICR Reference No: 202003-1240-003
Status: Historical Active	Previous ICR Reference No: 201710-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/13/2020
	Date Received in OIRA: 04/12/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	04/30/2021	04/30/2021
Responses	1,325	0	1,325
Time Burden (Hours)	679	0	679
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	1,325	1,325
Annual Time Burden (Hours)	679	679
Annual Cost Burden (Dollars)	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: The total decrease in the total burden hours for all three forms is 963 hours, with the current total burden hours being 679. The prior total burden hours for all three forms were 1,642. Form CM-623 decreased by 900 hours, with a current burden of 450 hours. The CM-623S increased by 37 hours, with a current burden of 54 hours. The CM-787 decreased by 100 hours, with a current burden of 175 hours. The total decrease in the total burden hours for all three forms is 963 hours. The CM-623 and CM-623S are no longer used as the annual accounting of a beneficiary’s benefits, but rather are just used for the final accounting of a beneficiary’s benefits, due to death or due to a change in representative payee appointment. The number of burden hours for form CM-787 has decreased due to fewer determinations of incapability or incompetence medical opinions needed.

Annual Cost to Federal Government: $13,857

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: Debbie Thurston 202 693-0913 Thurston.Debra@dol.gov

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