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OMB Control No: 1240-0013	ICR Reference No: 202604-1240-003
Status: Received in OIRA	Previous ICR Reference No: 202302-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 04/28/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2026
Responses	1,241	1,241
Time Burden (Hours)	1,063	1,063
Cost Burden (Dollars)	730	556

Annual Cost to Federal Government: $30,156

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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