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Claim for Continuance of Compensation
Claim for Continuance of Compensation
OMB: 1215-0154
IC ID: 13838
OMB.report
DOL/ESA
OMB 1215-0154
ICR 200802-1215-003
IC 13838
( )
Documents and Forms
Document Name
Document Type
Form CA-12
Claim for Continuance of Compensation
Form
CA-12 Claim for Continuance of Compensation Under the Federal
ca-12.pdf
www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Claim for Continuance of Compensation
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 10.126
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CA-12
Claim for Continuance of Compensation Under the Federal Employees' Compensation Act
ca-12.pdf
http://www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Survivor Compensation
Privacy Act System of Records
Title:
DOL/GOVT-1
FR Citation:
67 FR 16817
Number of Respondents:
4,850
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
4,850
0
0
-600
0
5,450
Annual IC Time Burden (Hours)
403
0
0
-51
0
454
Annual IC Cost Burden (Dollars)
1,988
0
0
-12
0
2,000
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
