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View ICR - OIRA Conclusion

OMB Control No: 1240-0015	ICR Reference No: 202310-1240-001
Status: Active	Previous ICR Reference No: 202005-1240-003
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: 01/08/2024
	Date Received in OIRA: 12/05/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	36 Months From Approved	01/31/2024
Responses	2,894	0	2,866
Time Burden (Hours)	241	0	239
Cost Burden (Dollars)	1,550	0	1,562

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	2,894	2,866	28
Annual Time Burden (Hours)	241	239	2
Annual Cost Burden (Dollars)	1,550	1,562	-12

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 estimated number of annual respondents (2, 894) is an increase of (28) from the previous request of (2, 866). The estimate in burden hours (241) is an increase of (2) from the previously approved (239). While the increase in respondents is not substantial, we attribute the increase in death benefits to eligible beneficiaries to COVID related deaths. There were no changes to the form itself, however, revisions were made to the Privacy Act and Public Burden Statements

Annual Cost to Federal Government: $41,922

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: Pamela Hamai 415 241-3350 hamai.pamela@dol.gov

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