Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements

Forms and Documents

Document Name	Status
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements Form	Modified
5 USC ACT Sections 8105, 8106, 8110, 8132, 8148.doc Supplementary Document	2007-08-29
20 CFR 10.528 for CA-1032.doc Supplementary Document	2007-08-29
NOTE TO REVIEWER - 1215-0151 Aug. 2007.doc Supplementary Document	2007-08-29
June 24, 2005 Final FECA Feasability Report - (CA-1032).pdf Supplementary Document	2007-08-29
THE PRIVACY ACT OF 1974.doc Supplementary Document	2007-08-29
DOL_GOVT-1.doc Supplementary Document	2007-08-29
Supporting Statement for 1215-0151 July 23, 2007.doc Supporting Statement A	2007-12-12

IC Document Collections

IC ID	Document Title	Status
13834	Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements Form	Modified

ICR Details

OMB Control No: 1215-0151	ICR Reference No: 200707-1215-004
Status: Historical Active	Previous ICR Reference No: 200412-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements
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: 02/06/2008
	Date Received in OIRA: 12/21/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	36 Months From Approved	02/29/2008
Responses	50,000	0	50,000
Time Burden (Hours)	16,667	0	16,667
Cost Burden (Dollars)	22,000	0	20,000

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Abstract: The CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

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Authorizing Statute(s): US Code: 5 USC 8101-8193 Name of Law: 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 49737	08/29/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 72760	12/21/2007
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Request for Information on Earnings, Dual Benefits, Dependents and Third Part Settlements	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents and Third Party Settlement

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ICR Summary 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	50,000	50,000	0	0	0	0
Annual Time Burden (Hours)	16,667	16,667	0	0	0	0
Annual Cost Burden (Dollars)	22,000	20,000	0	0	2,000	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:

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Annual Cost to Federal Government: $357,625

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: 12/21/2007

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