Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form	Modified	Available
DOL_GOVT-1.doc	Supplementary Document	Uploaded 2007-03-30	Available
SS for 1215-0202 CA-278 (January 2007).doc	Supporting Statement A	Uploaded 2007-03-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13940	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form	Modified

ICR Details

OMB Control No: 1215-0202	ICR Reference No: 200612-1215-003
Status: Historical Active	Previous ICR Reference No: 200402-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
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: 08/23/2007
	Date Received in OIRA: 05/22/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	08/31/2007
Responses	140	0	80
Time Burden (Hours)	70	0	40
Cost Burden (Dollars)	239	0	0

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Abstract: Information collected using Form CA-278 will allow OWCP to consider requests filed by insurance carriers and self-insured that have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees' Compensation Fund.

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Authorizing Statute(s): US Code: 42 USC 1701 Name of Law: War Hazards Compensation Act (WHCA)
   US Code: 5 USC 8147 Name of Law: The Federal Employees' Compensation Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 1248	01/10/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 28552	05/21/2007
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	CA-278	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

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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	140	80	0	0	60	0
Annual Time Burden (Hours)	70	40	0	0	30	0
Annual Cost Burden (Dollars)	239	0	0	0	239	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 has been an adjustment of 40 burden hours to 70 burden hours which is an increae of 30 burden hours as a result of the number of claims being submitted due to the conflict in Iraq. There has been a change in the operation and maintenance cost due to an increase in postage from $97.00 to $239.00.

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Annual Cost to Federal Government: $62,053

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

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Common Form ICR:  No

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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: 05/22/2007

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