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: 1240-0020	ICR Reference No: 202311-1240-007
Status: Active	Previous ICR Reference No: 202012-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
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 with change	Conclusion Date: 05/01/2024
	Date Received in OIRA: 03/29/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2027	36 Months From Approved	05/31/2024
Responses	282	0	1,325
Time Burden (Hours)	154	0	679
Cost Burden (Dollars)	192	0	769

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	282	1,325	-1,043
Annual Time Burden (Hours)	154	679	-525
Annual Cost Burden (Dollars)	192	769	-577

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: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents decreased from 1,325 to 282. Due to less beneficiaries needed a rep payee. Responses: The number of responses decreased from 1,325 to 282. Due to less forms submitted. Burden Hours: Total burden hours decreased from 679 to 153 due to the decrease of forms received. Costs: Annual burden costs decreased from $769 to $192 due to a decrease of responses submitted.

Annual Cost to Federal Government: $4,109

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: Marcela Meneses 304 420-1232 meneses.marcela@dol.gov

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