View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 1240-0012	ICR Reference No: 202008-1240-063
Status: Historical Active	Previous ICR Reference No: 201805-1240-007
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Rehabilitation Maintenance Certificate
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: 02/16/2021
	Date Received in OIRA: 12/15/2020
Terms of Clearance:

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

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	3,452	3,452
Annual Time Burden (Hours)	575	575
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: 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? No

Agency Contact: Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov

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