Agreement and Undertaking

Forms and Documents

Document Name	Status
Form OWCP-1 Agreement and Undertaking Form and Instruction	Modified
OMB 83-1 1215-0034 2008.pdf Supplementary Document	2008-09-16
SS for 1215-0034 09-11-2008[1].doc Supporting Statement A	2008-09-16
20 CFR 726.110 et seq.pdf Supplementary Document	2008-05-15
30 USC 933.htm Supplementary Document	2008-05-15

IC Document Collections

IC ID	Document Title	Status
13662	Agreement and Undertaking Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0039	ICR Reference No: 201003-1240-039
Status: Historical Active	Previous ICR Reference No: 200510-1215-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Agreement and Undertaking
Type of Information Collection: Revision 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	10/31/2011	36 Months From Approved
Responses	20	0	300
Time Burden (Hours)	5	0	75
Cost Burden (Dollars)	9	0	0

---

Abstract: The OWCP-1 is a form completed by employers to provide the Secretary of Labor with authorization to sell securities or to bring suit under indemnity bonds deposited by the self-insured employers in the event there is a default in the payment of benefits.

---

Authorizing Statute(s): US Code: 30 USC 933 Name of Law: Federal Coal Mine Health and Safety Act of 1969
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 31889	06/04/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 55134	09/24/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Agreement and Undertaking	OWCP-1	Agreement and Undertaking

---

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	20	300	0	-204	-76	0
Annual Time Burden (Hours)	5	75	0	-51	-19	0
Annual Cost Burden (Dollars)	9	0	0	9	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: The burden hours have been reduced from the previous submission of 75 hours to 5 hours. There has been a program change (-204 responses and -51 hours) due to a substantial reduction in burden hours and operation costs because of the discontinuance of this collection by the Division of Longshore and Harbor Workers' Compensation (DLHWC) (200 forms). DLHWC now uses forms LS-275ic and LS-275si, which together comprise OMB 1215-0204. There is an operation and maintenance cost of $9.00 for mailing for the 20 responses. In addition, use of the OWCP-1 by the Division of Coal Mine Workers' Compensation (DCMWC) is declining because of mergers and consolidation of coal mine operators in which a single operator self-insures a number of subsidiaries (an adjustment of -76 responses and -19 burden hours).

---

Annual Cost to Federal Government: $76

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

---

Common Form ICR:  No

---

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: 09/24/2008

---