View Information Collection Request (ICR) Package

OMB Control No: 1240-0016	ICR Reference No: 202104-1240-001
Status: Historical Active	Previous ICR Reference No: 202003-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
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: 03/31/2022
	Date Received in OIRA: 01/21/2022
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	11/30/2023	11/30/2023
Responses	37,056	0	37,056
Time Burden (Hours)	12,228	0	12,352
Cost Burden (Dollars)	15,030	0	15,030

Abstract: Form CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

Authorizing Statute(s): US Code: 5 USC 8116 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8148 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8110 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:
	86 FR 30335	06/06/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 3355	01/21/2022
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	CA-1032

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	37,056	37,056	0
Annual Time Burden (Hours)	12,228	12,352	-124
Annual Cost Burden (Dollars)	15,030	15,030	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: There are no changes with the previous submission related to number of respondents and IC cost burden dollars, which remains 37,056, and $15,030, respectively. However, the previously approved burden hours, 12,352, is reduced to 12,228 (a decrease of 124) due to rounding of the average burden hour to “.33 versus .33333333333”. In addition, the revision to this ICR only affects a change to a question in PART D--OTHER FEDERAL BENEFITS OR PAYMENTS of Form CA-1032. This change was necessary to help clarify the question regarding the respondent's receipt of Social Security benefits in conjunction with Federal Employees' Retirement System (FERS) benefits due to Federal service. Such receipt receipt requires an offset from compensation benefits for disability and the question was rephrased to better clarify the information needed. Specific changes are noted as follows and are outlined in Question15 of the Supporting Statement.

Annual Cost to Federal Government: $426,539

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

View ICR - OIRA Conclusion