SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION
Report of Public Safety Officer=s Permanent and Total Disability
A. JUSTIFICATION
1. Necessity of Information: The Public Safety Officers= Benefits Act of 1976 (PSOB), 42 U.S.C. 3796, authorizes the Bureau of Justice Assistance, Office of Justice Programs to pay a benefit to claimant public safety officers found to have been permanently and totally disabled as the direct result of a catastrophic line of duty injury sustained on or after November 29, 1990. The Report of Public Safety Officer=s Permanent and Total Disability form is completed by the disabled officer and his/her former employing public safety agency. The form and supporting documentation are filed with the Public Safety Officers’ Benefits Office, Bureau of Justice Assistance (BJA) to apply for disability benefits under the PSOB Act.
2. Purpose for Use: The information collected is pursuant to the PSOB Act to determine the eligibility of permanently and totally disabled public safety officers for the payment of benefits. The form includes information necessary to determine that the circumstances that lead to the disability meet the requirements prescribed in 42 U.S.C, ' 3796.
3. Use of Information Technology: The Report of Public Safety Officer=s Permanent and Total Disability form (OJP FORM 3650/7) is available for downloading from the Bureau of Justice Assistance website at;
http://www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html.
Supporting documentation can be submitted via mail or fax as indicated below. The same contact information can be used to receive and submit the disability form from and to the PSOB Office.
Office of Justice Programs, Bureau of Justice Assistance
Public Safety Officers’ Benefits Office
810 Seventh Street, NW
Washington, DC. 20531
1-888-744-6513 Toll free
202-616-0314 Fax
4. Identification of Duplication: This is the only federal program providing this specific service. The information collection does identify whether or not claims have been filed under the Federal Employees Compensation Act and the D.C. Retirement and Disability Act. The PSOB application is the only form that asks the information required to determine if an individual is eligible for the PSOB disability benefits.
5. Impact on Small Businesses or Other Entities: The information collection requirements do not impact small businesses or other entities as described in the instructions for completing OMB Form 83-I.
6. Consequences if Collection is not Conducted: The form must be completed only once. Without the statutorily-required information collected on the form, BJA would not be able to confirm that applicants are eligible for the disability benefits, and it would not be able to authorize payments.
7. Special Circumstances: None.
8. Publication: The 60 and 30 day federal registers notices were published, and no comments were received. The application period is open continuously.
9. Payment to Respondents: The completion and successful processing of this application will entitle the applicant to receive a one-time disability benefit in the amount of $311,810.00 (FY 2010).
10. Assurance of Confidentiality: All information on the form is collected in accordance with the Privacy Act of 1974, as amended. OJP is compliant with 28CFR22 which protects confidentiality of identifiable and statistical information and is committed to keeping a system of records that is consistent with the regulations of the Privacy Act.
11. Questions of a Sensitive Nature: By their nature, questions addressing the circumstances of officers’ injuries, their medical backgrounds, and information related to their employing public agencies are inherently sensitive. These inquiries must be made to determine if there are any disqualifying factors concerning an officer’s disability with regard to eligibility under the PSOB Program.
12. Estimate of the Hour Burden: Annual Hour Burden
Number of Respondents: 100
Number of applications submitted per respondent: 1 application
Total annual applications: 100 x 1 = 100
Hours per application: 120 minutes
Total Annual Reporting Burden: 100 x 120 minutes per application = 12,000 minutes / by 60 minutes per hour = 200 hours.
13. Estimate of the Total Annual Cost Burden: There is no capital or start up costs associated with information collection under this program. The cost to the respondents is the time (approximately 120 minutes) spent completing the form, gathering the information and transmitting the required documentation.
14. Estimates of Annualized Cost to the Federal Government: The assigned program manager for this program is paid at an annual rate of a GS-13/5 at $ 100,904 per year, plus $ 22,199 (or 22% in fringe benefits) = $ 123,103/52 weeks/40 hours per week equal an hourly rate of $ 59.19. Each application review takes approximately 120 minutes. $59.19 x 2.5 hours (150 minutes) = $ 148.00 per application review. 100 x $ 128.53
= $ 14,798.00
15. Program Changes or Adjustments: None. This is a request for an extension, without change, of a previously approved collection form, with approval expiring on May 31, 2010.
16. Publishing Information: The information collected will not be published.
17. Approval to not Display the OMB Approval: The present information collection request does not seek such an approval.
18. Certification for Paperwork Reduction Act Submission: See attached Certification Statement.
M. Berry: H. Janke
Feb 2010
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION |
| Author | presslem |
| Last Modified By | Lynn Bryant |
| File Modified | 2010-05-19 |
| File Created | 2010-05-19 |