SUPPORTING STATEMENT
Application for Continuation of Death Benefit for Student
(LS-266)
OMB No. 1215-0073
A. Justification.
1. The Office of Workers' Compensation Programs, (OWCP) administers the Longshore and Harbor Workers' Compensation Act.
This Act was amended on October 27, 1972, to provide for continuation of death benefits for a child or certain other surviving dependents after the age of 18 years (to age 23) if the dependent qualifies as a student as defined in section 2 (18) of the Act. The benefit would also be terminated if the dependent completes four years of education beyond high school. Form LS-266 is to be submitted by the parent or guardian for whom continuation of benefits is sought. Upon a student’s 18th birthday, a letter is sent to the student (parent) to inform them that benefits will terminate unless the student is still a full-time student. The form is included for the parent (student) to complete if the student is still enrolled full time. The form is sent again yearly (at least) to ensure that the student’s status has not changed. This ends when the student turns 23 years old. The statements contained on the form must be verified by an official of the educational institution. The information is used by the DOL to determine whether a continuation of the benefits is justified.
Legal authority for this information collection is found at
33 USC 902(18) and 33 USC 939(a). Regulatory authority is at
20 CFR 702.121.
2. The information collected from the LS-266 is used by the OWCP to assure that a claimant receives all of the benefits under the Act to which he/she may be entitled to receive. If the information were not collected, there would be no way to determine the proper status of a student and therefore his/her continued entitlement to benefits.
3. In accordance with the Government Paperwork Elimination Act (GPEA), this information collection is not practicable for electronic submission. The extremely small number of respondents, the need for two separate electronic signatures from respondents at different locations, and the even smaller number of respondents who would have access to an electronic option given the need for electronic signatures, make electronic submission impracticable and not cost effective for this population of respondents. While the document is not available for electronic submission it is available on our website for completion online and printing prior to the parties affixing their signatures and submission to the appropriate district office. The website is: http://www.dol.gov/esa/owcp/dlhwc/ls-266.pdf. The LS-266 can also be accessed through DOL’s on-line forms library at http://www.dol.gov/libraryforms/FormsByNum.asp.
4. All forms in the Longshore program have been carefully reviewed to eliminate all requests for duplicate information.
To the extent that colleges and universities are considered
as small businesses, burden has been kept to a minimum in that little more than a certification is needed from the college or university to verify the information provided on the form by the parent or guardian. This information collection does not have a significant impact on a substantial number of small entities.
6. The information is requested only on occasion when needed and therefore cannot be collected less frequently.
7. There are no special circumstances for the collection of this information.
8. The form is primarily completed by parents and guardians of dependents who are also students. A very small number of forms are completed each year. The form also requests only basic claims information needed to verify entitlement to benefits. Given the nature of the claims examining process, the OWCP has daily contact with claimants and industry representatives that submit forms under the Act. The adequacy of the data submitted is discussed as well as the format. Pursuant to these discussions, forms are periodically revised.
A Federal Register Notice inviting public comment was published on August 22, 2007. No comments were received.
9. No payment or gift is provided to respondents.
10. Records pertaining to compensation cases are covered under the Privacy Act at DOL/ESA-15. The system name is Office of Workers' Compensation Programs, Longshore and Harbor Workers’ Compensation Act case files.
11. There are no questions of a sensitive nature.
12. Based on information from existing files and new death claim submissions, it is estimated that approximately 43 Forms LS-266 will be used each year to apply for the continuation of a death benefit for an eligible student. The eligible student would be both between the age of 18 and 23, and enrolled full time. It is estimated that approximately 30 minutes or .5 hours will be needed to obtain the information required by the form and to complete it. This estimate includes the time needed by the parent or guardian and the official of the institution in which the student is enrolled. This estimate is considered reasonable in light of the type of information requested and the fact that the information should be readily available to those persons completing the forms. This estimate also takes into consideration that the parent or guardian may complete an additional copy of the form rather than use a photocopy of the original. Total annual burden for 43 forms at 30 minutes each is 22 hours 43 X .5 hours = 21.50 rounded to 22).
The annualized burden cost to the respondents has been estimated to be approximately $283.00. This estimate is derived from use of the National Average Weekly Wage (NAWW) as computed by the Bureau of Labor Statistics and which is based on the national average earnings of production or nonsupervisory workers on private nonagriculture payrolls. Section 6(b) of the Act mandates the use of the NAWW in setting the maximum and minimum compensation rates under the Act and in determining the amount of annual adjustments due to permanent total disability and death beneficiaries. Since it is not possible to determine the specific occupation or wages for each person who will provide the information covered by this clearance, and wages can vary considerably from person to person depending on duties and length of service, use of a national average weekly wage covering all occupations appears reasonable under the circumstances. The current applicable NAWW is $515.39. The computations are therefore as follows: $515.39 40 hrs = $12.88/hr x 22 hrs = $283.36 annualized burden cost.
13. This information collection does not require the use of systems or technology for generating, maintaining or disclosing the data above that which would already be kept as a customary business practice. A mailing cost of $.41 per response for postage and $.03 for envelopes is applied as an operation cost, with a total of $18.92 rounded to $19.00 for the 43 responses.
14. The cost to the government has been estimated to be approximately $127.96 rounded to $128.00. This estimate was determined by taking into consideration printing, distribution and analysis costs associated with the issuance and review of Form LS-266. The cost to print a two-sided form is $4.50 per 100 copies. Distribution costs were determined by applying a postage and envelope charge ($.41 and $.03 respectively) against the number of copies issued. Analysis and handling costs were determined by applying the hourly rate of a GS-12 claims examiner ($30.39/hr) to the total annual hours required for review. The annual review hours were determined by applying an estimate of .08 hour or 5 minutes for the review and analysis of each form against the 43 forms which are received each year. The Salary Table 2007-RUS was used for the claims examiner. The computations are as follows:
Printing $4.50 (100 copies at $4.50/100 copies)
Distribution 18.92 (43 forms x $.44)
Analysis 104.54 (3.44 hrs x $30.39/hr)
Total $127.94
15. There has been no change in burden for this form. There has been a change in the operation and maintenance cost due to an increase in postage from $17.20 to $18.92 rounded to $19.00.
16. The information collected will not be published for statistical use.
17. The expiration date will be displayed.
18. There are no exceptions to the certification.
| File Type | application/msword |
| File Title | .Justification Statement LS-266 |
| Author | Unknown |
| Last Modified By | king-darrin |
| File Modified | 2008-01-15 |
| File Created | 2008-01-15 |