SUPPORTING STATEMENT
Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA-721) and Notice of Law Enforcement Officer’s Death (CA-722)
OMB No. 1240-0022 (Formerly 1215-0116)
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.
The Federal Employees' Compensation Act (FECA) provides, under 5 U.S.C. 8191, et.seq. and 20 CFR 10.735, that non-Federal law enforcement officers injured or killed under certain circumstances are entitled to the benefits of the Act, to the same extent as if they were employees of the Federal Government. The CA-721 and CA-722 are used by non-Federal law enforcement officers and their survivors to claim compensation under the FECA. Form CA-721 is used for claims for injury. Form CA-722 is used for claims for death.
2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
These forms are the device by which notices of injury, claims for compensation, and claims for death benefits are filed by non-Federal law enforcement officers and their survivors. The information contained in the forms is used to help determine if the case is covered and what further issues to develop. For example, was the injury sustained under circumstances bringing it within 5 U.S.C. 8191, was the injury disabling, is the disability due to the injury, are those filing a claim entitled to compensation, what further information is required to reach a decision, etc.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
The forms CA-721 and CA-722 can be completed on-line and printed and are available for downloading from the Internet at http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
The information requested on these forms is not duplicative of any information available elsewhere. The claimant, beneficiary, employer, and physician are the only sources of the required information.
5. If the collection of information impacts small businesses or other small entities (Item 5 of 014B Form 83-1), describe
any methods used to minimize burden.
The only involvement of small businesses is physicians who complete the medical documentation portion of the form. This information collection does not have a significant economic impact on a substantial number of small business entities.
6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
The information is collected only once. Without the requested information, no determination could be made regarding the payment of benefits.
7. Explain any special circumstance.
There are no special circumstances impacting this collection.
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
No outside consultants were contacted concerning the use of forms CA-721 and CA-722.
A notice inviting public comment (under the former OMB Control No. 1215-0116) on this information collection was published in the Federal Register on March 15, 2010. No comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gifts are provided to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
All information contained in FECA claim files is fully protected under the Privacy Act in the system of records known as DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal Employees' Compensation Act File)
(http://www.dol.gov/sol/privacy/dol-govt-1.htm)
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
None of these forms ask questions of a sensitive nature.
12. Provide estimates of the hour burden of the collection of information. The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.
The response times below were based on the length of time that it will take respondents to complete the forms and obtain the necessary information. Both require full explanations of how injury or death occurred, the federal crime involved, etc.
CA-721 60 minutes 6 forms 6 hours
CA-722 90 minutes 7 forms 11 hours
Total 13 responses 17 hours
Because the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage median wages of productions workers as computed by BLS, or $12.86 per hour ($12.86 X 40 hours = $514.40). http://www.bls.gov/oes/current/oes519199.htm http://www.bls.gov/oes/current/oes519199.htm (as of May 2008)
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
There is no capital/startup or ongoing operation/maintenance costs associated with this information collection. Operation and maintenance costs consist solely of mailing costs. There are 13 annual responses at ($0.44 for postage + $0.03 for an envelope) = i.e., 13 x $.47 = $6.11, or rounded to $6.00.
14. Federal Cost Estimate:
Printing Costs: Due to the small number of claims received, there are no plans to print the form in bulk for distribution
Mailing and Developmental Costs: Claimants and employers are able to download forms CA-721 and CA-722 directly from the internet; therefore, no mailing costs for the forms will be incurred. However, development usually occurs in these types of cases, therefore, mailing costs for development of the claim = ($.44 postage and $.03 for envelope per response) 13 x $.47 = $6.11 or $6.00 rounded.
Processing Cost: All claims are reviewed and adjudicated by Claims Examiners located in the Cleveland district office with an average grade of GS-12 step 7 at an hourly wage of $41.13.
13 Forms X 1/3 of an hour each X 41.13 = $178.23 or $178.00 rounded.
The Federal cost for mailing and processing of claims is $184.00 ($178.00 + $6.00)
http://opm.gov/oca/10tables/pdf/cle_h.pdf
http://opm.gov/oca/10tables/html/cle_h.asp
15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.
There is a decrease in 23 burden hours due to a reduction in the number of claims that have been filed which is an adjustment of minus 17. There has been a decrease in the operational and maintenance costs, from $13.20 ($13.00) to $6.00, for a decrease of $7.00, due to a reduction in the number of submitted claims.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
Data collected with these forms will not be published.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate
The form will display the expiration date.
18. Explain each exception to the certification statement
identified in Item "Certification for Paperwork Reduction Act
Submissions," of OMB Form 83-I.
There are no exceptions to certification.
| File Type | application/msword |
| File Title | Supplemental Statement |
| Author | US Department of Labor |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2010-07-23 |
| File Created | 2010-07-23 |