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View ICR - OIRA Conclusion

OMB Control No: 1240-0039	ICR Reference No: 202401-1240-001
Status: Active	Previous ICR Reference No: 202012-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Agreement and Undertaking
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: 06/21/2024
	Date Received in OIRA: 05/20/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2027	36 Months From Approved	06/30/2024
Responses	20	0	17
Time Burden (Hours)	5	0	4
Cost Burden (Dollars)	4	0	2

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	20	17	3
Annual Time Burden (Hours)	5	4	1
Annual Cost Burden (Dollars)	4	2	2

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 CHANGES Respondents: The number of respondents increased from 17 to 20. Due to increased on self-insured companies. Responses: The number of responses increased from 17 to 20. Due to increase of forms submitted. Burden Hours: Total burden hours increased from 4 to 5 due to the increase of responses. Costs: Annual burden costs increase from $2.32 to $3.65 due to a decreased of responses submitted.

Annual Cost to Federal Government: $121

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. No

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. No

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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