Statement of Recovery Forms

Forms and Documents

Document Name	Status
Form ca-1122 Statement of Recovery Form and Instruction	New
Form ca-1108 Claim for Reimbursement-Assisted Reemployment Form and Instruction	Modified
supporting statement 1215-0200 05 04 2009[1].doc Supporting Statement A	2009-05-04
NOTE TO REVIEWER.doc Supplementary Document	2009-04-14

IC Document Collections

IC ID	Document Title	Status
188783	Statement of Recovery Form and Instruction	New
13938	Claim for Reimbursement-Assisted Reemployment Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0200	ICR Reference No: 200811-1215-005
Status: Historical Active	Previous ICR Reference No: 200604-1215-003
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Statement of Recovery Forms
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: 06/15/2009
	Date Received in OIRA: 05/18/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2012	36 Months From Approved	06/30/2009
Responses	3,000	0	3,200
Time Burden (Hours)	1,425	0	1,520
Cost Burden (Dollars)	1,350	0	1,000

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Abstract: These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.

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Authorizing Statute(s): US Code: 5 USC 8131 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 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:
	73 FR 79194	12/24/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 23207	05/18/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Claim for Reimbursement-Assisted Reemployment	ca-1108	Statement of Recovery
Statement of Recovery	ca-1122	Statement of Recovery

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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	3,000	3,200	0	0	-200	0
Annual Time Burden (Hours)	1,425	1,520	0	0	-95	0
Annual Cost Burden (Dollars)	1,350	1,000	0	0	350	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 adjustments in the burden hours are due to a decrease in the number of third party claims. The previous approved number of annual responses, 3200, is being reduced to 3,000, which represents a reduction of 200 respondents. The approved number of hours is 1520 and the requested number of hours is 1425,a decrease of 95. In addition, due to an increase in postage, the maintenance and reporting costs have increased from $1,000 to $1,350, which is an increase of $350.00.

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Annual Cost to Federal Government: $43,185

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)? No

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: 05/18/2009

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