revised Supporting Statement for 1215-0167 (CA-2a) Decmenber 2007hb4-11-08

Supporting Statement

Notice of Recurrences (CA-2a)

OMB NO.1215-0167

A. Justification.

1. The Office of Workers’ Compensation Programs administers the Federal Employees’ Compensation Act,(5 USC 8101,et seq.), which provides for continuation of pay or compensation for work related injuries or disease that result from Federal Employment. Regulation 20 CFR 10.104 designates form CA-2a as the form to be used to request information from claimants with previously accepted injuries who claim a recurrence of disability, and from their supervisors. The form requests information relating to the specific circumstances leading up to the recurrence as well as information about their employment and earnings.

In the vast majority of cases, recurrences of disability are claimed while a claimant continues to be employed by the Federal Government. In those cases, the form is completed by a Federal employee and their federally employed supervisor, and thus does not affect the public. The form is required from the public when the claimant is a former employee and part of the general public when the recurrence occurs. In this case, there is no official supervisor. However, since the same information is required of both former and current employees, all the claimant information must still be provided by the claimant. The last Federal employer of a former employee is asked to provide information about the claimant when they returned to work after the original injury or when last employed as a Federal employee. It is estimated that 5% of all claims (680 of 13,596 total recurrences filed) are filed by claimants after leaving Federal employment. Therefore, this request for clearance pertains to about 5% of the overall use of this form.

http://www.access.gpo.gov/uscode/title5/partiii_subpartg_chapter81_subchapteri_.html

http://www.access.gpo.gov/nara/cfr/waisidx_07/20cfr10_07.html

2. The information provided is used by OWCP claims examiners to determine whether a claimant has suffered a recurrence of disability related to an accepted injury and, if so, the appropriate benefits payable.

3. In accordance with the Government Paperwork Elimination Act (GPEA), the Form CA-2a is available on-line in a PDF fillable and printable format at http://www.dol.gov/esa/regs/compliance/owcp/ca-2a.pdf. The CA-2a can also be accessed through DOL’s DFEC on-line forms library at http://www.dol.gov/libraryforms/FormsByNum.asp. This form has not been made available for electronic submission for the following reasons.

1) The majority of respondents to the form are FEDERAL EMPLOYEES (12,916 annually)and are not members of the GENERAL PUBLIC, while only 5% (680 annually) of the respondents are no longer on the AGENCY ROLLS and are therefore members of the GENERAL PUBLIC.

2) The form requires multiple signatures. If any one entity in the approval chain does not have access to electronic filing or does not own a digital signature, the submission process for the form will terminate prematurely. This would then require OWCP to reprocess the form in a paper format for proper completion, which is duplicative and defeats the purpose of the (GPEA).

3) A Public Key Infrastructure (PKI) certificate would cost the agency between $25.00 and $35.00, compared to mailing costs of 44¢ for each mailed submission. In addition, DOL would need to develop the web pages for employers to submit the information. These development costs would easily exceed the total annual mailing costs of $299 for all respondents filing paper forms CA-2a and would not be justified for an information collection that receives less than the minimal requirement of 5,000 annual responses for implementation of an electronic option.

4. The information requested on the Form CA-2a is not duplicative of any information available elsewhere. The claimant is the only source of this information.

5. This information collection does not have an effect on small businesses.

6. This form is only required one time for each recurrence claimed by an individual. All of the evidence requested by the form is necessary for OWCP to determine what benefits are payable for a claimed recurrence. Without the requested information an eligible beneficiary could be denied benefits, or benefits could be authorized at an incorrect rate, resulting in an underpayment or overpayment of compensation.

7. There are no special circumstances for the collection of this information.

8. Previously, a Federal Register Notice inviting comment was published on December 18, 2007 (72-71699). No comments were received.

9. No payment or gift is provided to respondents.

10. The information collected by this form is maintained in FECA claim files, which are fully protected under the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1. The Privacy Act Statement is displayed on the form. http://www.usdoj.gov/oip/privstat.htm and http://www.dol.gov/sol/privacy/dol-govt-1.htm

11. This form does not ask questions of a sensitive nature and disclosure of the Social Security Number is authorized by P.L. 103-296, Section 318.

http://www.socialsecurity.gov/policy/docs/ssb/v58n1/v58n1p57.pdf

12. The CA-2a requires the respondent to provide the information on events leading to a recurrence of disability, medical condition, employment and earnings. Since the claimant should have the requested information readily available, it would simply be a matter of filling out the form. Past experience with this form indicates that it will take approximately 30 minutes for the completion of the form, including reading instructions and providing all requested information.

1/2 hour x 680 = 340 hours

The information does not require looking up any records, and is readily known to the respondent. This form is used by an individual to voluntarily initiate a claim for monetary benefits. Because the wage category of most of the respondents is not known, we have estimated the cost of the burden hours using the National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS, or per hour:

$16.76 X 340 hrs. = $5,698 respondent cost. http://www.bls.gov/ces/cesbtabs.htm

13. Operating and maintenance costs consist of the price of postage and envelope to return the form.

41¢ postage + 3¢ for the envelope X 680 = $299.00.

14. Cost to the Federal government:

Time to review each form - 1/2 = .50 of an hour

Hourly wage of reviewer - $29.59(GS-11/5)

http://www.opm.gov/oca/08tables/html/RUS_h.asp

680 forms x .50 = 340 hours X $29.59 = $ 10,061 = processing costs

Processing Cost - $ 10,061

Printing Costs - $ 50 The printing cost have stayed the

same because the number being printed is lower.

Mailing Costs -

$ 299

Total - $10,410

15. There are currently 13,596 recurrences being submitted, a decrease of 566 claims. There is a decrease of 28 in the number of claims being submitted by claimants who have left federal employment (i.e. 5% of 13,596 = 680 versus 708 in the previous submission), which results in a burden hour reduction of 28 x.50 = -14 in this submission. The reporting burden hours in the previous submission were 354 and have changed to 340 hours. The operation and maintenance cost has increased from $283 to $299 due to an increase in the cost of postage from 37¢ to 41¢.

16. The information collected with this form will not be published.

17. No exception to display of the expiration date is sought.

18. There are no exceptions to certification.

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