Claim for Damage Injury or Death

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CIV-SF-95 Claim for Damage Injury or Death	Form	Modified	Available
SF 95 83C Dec 2006.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2006-12-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
11731	Claim for Damage Injury or Death	Form	Modified

ICR Details

OMB Control No: 1105-0008	ICR Reference No: 200612-1105-002
Status: Historical Active	Previous ICR Reference No: 200507-1105-002
Agency/Subagency: DOJ/LA	Agency Tracking No:
Title: Claim for Damage Injury or Death
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/26/2007
	Date Received in OIRA: 12/27/2006
Terms of Clearance: The proposed changes are changes due to adjustments in agency estimate not program chantges due to agency discretion.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2009	02/28/2009	02/28/2009
Responses	400,000	0	3,000,000
Time Burden (Hours)	2,400,000	0	1,800,000
Cost Burden (Dollars)	0	0	0

---

Abstract: This form is utilized by those persons making a claim against the United States Government under the Federal Tort Claims Act.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Damage Injury or Death	CIV-SF-95	Claim for Damage, Injury, or Death

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400,000	3,000,000	0	0	-2,600,000	0
Annual Time Burden (Hours)	2,400,000	1,800,000	0	0	600,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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 Civil Division previously reported 300,000 annual respondents for the Claim for Damage, Injury, or Death information collection (the “SF 95,” OMB control number 1105-0008). Since the Division estimates that it takes a respondent six hours to complete the form, the total annual burden for 300,000 respondents is 1,800,000 hours. After speaking with federal agencies that receive a large number of tort claims and due to events surrounding Hurricane Katrina, the Civil Division is increasing its expected number of annual respondents to 400,000 with a total burden of 2,400,000 hours. This information collection is used to file a tort claim against the United States Government. A lawsuit against the United States Government may be brought under the Federal Tort Claims Act (the “FTCA”) only if the claimant first seeks administrative relief from the proper federal agency. Use of the SF 95 Form facilitates this process because it identifies the information that is necessary to present a valid claim. In previous years, the Civil Division reported an estimate of 300,000 annual respondents for the SF 95 Form. After speaking with several federal agencies that generate a substantial number of annual tort claims, the Civil Division estimates that in an average year there will only be approximately 100,000 respondents. However, the unusual events surrounding Hurricane Katrina will cause an increase in the number of tort claims over the next year. On August 29, 2005, Hurricane Katrina made landfall causing several breaches in the levees around New Orleans, Louisiana. Most of the city of New Orleans was flooded. Hurricane Katrina was the costliest and one of the deadliest hurricanes in the history of our nation. Hundreds of thousands of people were displaced from their homes, and thousands of schools, hospitals, and other businesses were damaged or destroyed. The Louisiana Recovery Authority estimates the economic losses, as well as property and infrastructure damages, to exceed $60 billion. In total, more than 600,000 people were displaced, 275,000 homes were destroyed, and 1,071 people died. (See “Overview of the Comparative Damage from Hurricane Katrina & Rita,” Louisiana Recovery Authority. Available electronically at www.lra.louisiana.gov/reports.html.). Many FTCA claims will be brought against the United States Government. To bring a claim against the Government, a claimant must first file a written claim with the appropriate federal agency within two years of the event. Therefore, all claims must be filed on or around August 29, 2007. To date, the Army Corps of Engineers has received some 24,000 claims. In total, more than 600,000 people were impacted by the flooding associated with Hurricane Katrina, and thus claims involving more than 600,000 people could be filed. The Civil Division estimates that 300,000 SF 95 Forms will be submitted in FY 2007 due to Hurricane Katrina. (While more than 600,000 people were affected, it is possible that families will jointly file one claim against the United States Government resulting in only 300,000 completed SF 95 Forms.) The combination of 100,000 normal respondents and the one-time 300,000 Katrina-related respondents will cause the FY 2007 estimate for the number of completed SF 95 Forms to be 400,000. At six hours per response, the total annual burden will be 2,400,000 hours.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/27/2006

---