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: 1240-0015	ICR Reference No: 202005-1240-003
Status: Historical Active	Previous ICR Reference No: 202002-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Continuance of Compensation (CA-12)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/21/2021
	Date Received in OIRA: 10/16/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2024	36 Months From Approved	01/31/2021
Responses	2,866	0	3,552
Time Burden (Hours)	239	0	295
Cost Burden (Dollars)	1,562	0	1,847

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	2,866	3,552	-686
Annual Time Burden (Hours)	239	295	-56
Annual Cost Burden (Dollars)	1,562	1,847	-285

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 are currently 2,866 individuals receiving death benefits vs. 3,552, which was reported in the previous OMB submission, a difference of 686 respondents. The annual Information Collection Time Burden is 239 hours which is a decrease of 56 hours based on the previous reporting hours of 295.

Annual Cost to Federal Government: $19,619

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? No

Agency Contact: Susan Price 202 693-0045 ext. 622052 price.susan@dol.gov

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