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: 1240-0016	ICR Reference No: 202306-1240-003
Status: Active	Previous ICR Reference No: 202304-1240-010
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
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: 11/01/2023
	Date Received in OIRA: 09/25/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2026	36 Months From Approved	11/30/2023
Responses	33,372	0	37,056
Time Burden (Hours)	11,013	0	12,228
Cost Burden (Dollars)	15,198	0	15,030

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	33,372	37,056	-3,684
Annual Time Burden (Hours)	11,013	12,228	-1,215
Annual Cost Burden (Dollars)	15,198	15,030	168

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 previous approved number of annual respondents, 37,056 is now 33,372 which represents a decrease of 3,684. The previously approved number for burden hours was 12,228 the requested number now is 11,013, a decrease of 1,215 hours.

Annual Cost to Federal Government: $416,449

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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