Rehabilitation Maintenance Certificate

Forms and Documents

Document Name	Status
Form OWCP-17 Rehabilitation Maintenance Certificate Form	Modified
SS 1215-0161 (OWCP-17) 04-30-2009Revised (3).doc Supporting Statement A	2009-05-18
DOL GOVT-1 1215-0161 (2009).pdf Supplementary Document	2009-04-29
DOL ESA-15- 1215-0161 (2009).pdf Supplementary Document	2009-04-29

IC Document Collections

IC ID	Document Title	Status
43809	Rehabilitation Maintenance Certificate Form	Modified

ICR Details

OMB Control No: 1240-0012	ICR Reference No: 201003-1240-012
Status: Historical Active	Previous ICR Reference No: 200606-1215-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Rehabilitation Maintenance Certificate
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: 03/12/2010
	Date Received in OIRA: 03/12/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2012	36 Months From Approved
Responses	15,600	0	15,600
Time Burden (Hours)	2,605	0	2,605
Cost Burden (Dollars)	0	0	0

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Abstract: The OWCP-17 serves as a bill submitted by the program participant or OWCP, requesting reimbursement of expenses incurred due to participation in an approved rehabilitation effort for the preceding four-week period of fraction thereof.

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Authorizing Statute(s): US Code: 33 USC 908 Name of Law: LHWCA
   US Code: 5 USC 8111 Name of Law: FECA
  

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:
	74 FR 6659	02/10/2009
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: 1

IC Title	Form No.	Form Name
Rehabilitation Maintenance Certificate	OWCP-17	Rehabilitation Maintenance Certificate

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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	15,600	15,600	0	0	0	0
Annual Time Burden (Hours)	2,605	2,605	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: $315,658

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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