Notice of Recurrence

Forms and Documents

Document Name	Status
Form ca-2a Notice of Recurrence Form and Instruction	Modified
revised Supporting Statement for 1215-0167 (CA-2a) Decmenber 2007hb4-11-08.doc Supporting Statement A	2008-04-11
5 USC 8101 et seq..pdf Supplementary Document	2008-03-13
20cfr10.104.pdf Supplementary Document	2008-03-13

IC Document Collections

IC ID	Document Title	Status
13870	Notice of Recurrence Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0167	ICR Reference No: 200803-1215-003
Status: Historical Active	Previous ICR Reference No: 200505-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Notice of Recurrence
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: 05/28/2008
	Date Received in OIRA: 04/25/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2011	36 Months From Approved	07/31/2008
Responses	680	0	708
Time Burden (Hours)	340	0	354
Cost Burden (Dollars)	299	0	0

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Abstract: This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.

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Authorizing Statute(s): US Code: 5 USC 8101, et seq 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 71699	12/18/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 22432	04/25/2008
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
Notice of Recurrence	ca-2a	Claim for Recurrence

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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	680	708	0	0	-28	0
Annual Time Burden (Hours)	340	354	0	0	-14	0
Annual Cost Burden (Dollars)	299	0	0	0	299	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: There is a decrease of 28 in the number of claims being submitted by claimants who have left federal employment, which results in a burden hour reduction of -14.

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Annual Cost to Federal Government: $10,410

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: 04/25/2008

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