Claim for Compensation by Dependents Information Reports

Forms and Documents

Document Name	Status
Form CA-5 Claim for Compensation by Dependents Information Reports Form and Instruction	Modified
dol-govt-1[1].doc Supplementary Document	2010-04-29
20 cfr 10.7 -1 0.537.pdf Supplementary Document	2010-04-29
2009 Weekly wage for prodcution or nonsupervisory workers on private nonagricultural payrolls.doc Supplementary Document	2010-04-29
8110.doc Supplementary Document	2010-04-29
SS 1240-0013 supporting statement revised[1].doc Supporting Statement A	2010-05-24

IC Document Collections

IC ID	Document Title	Status
13841	Claim for Compensation by Dependents Information Reports Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0013	ICR Reference No: 201004-1240-013
Status: Historical Active	Previous ICR Reference No: 201003-1240-013
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by Dependents Information Reports
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: 07/21/2010
	Date Received in OIRA: 05/28/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2013	36 Months From Approved	07/31/2010
Responses	1,358	0	1,880
Time Burden (Hours)	870	0	1,077
Cost Burden (Dollars)	638	0	452

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Abstract: These reports request information from the survivors of deceased Federal employees which verify dependents status when making a claim for benefits and on a periodic basis in accepted claims. Some of the forms are used to obtain information on claimed dependents in disability cases.

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Authorizing Statute(s): US Code: 5 USC 8101 et seq. Name of Law: Augmented Compensation for Dependents
  

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:
	75 FR 4587	01/28/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 60062	05/28/2010
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
Claim for Compensation by Dependents Information Reports	CA-5, CA-5B, CA-1031, CA-1074	Claim for Compensaion by Widow, Widower, and/or Children ,   Claimant Support of Dependent ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandshildren ,   Request for Clarification of CA-5b

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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	1,358	1,880	0	0	-522	0
Annual Time Burden (Hours)	870	1,077	0	0	-207	0
Annual Cost Burden (Dollars)	638	452	0	186	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: The adjustment in the burden hours is due to having a better accountability of tracking receipt of responses via a computer data base. The previous number of annual respondents of 1880, is being reduced to 1358, which represents a reduction of 522 respondents. The approved number of hours is 1077 and the requested number is 870, a decrease of 207. Due to an increase in postage from $0.42 to $0.47, maintenance and reporting costs increased from the approved amount of $452, to $638, which represents an increase of $186.00.

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Annual Cost to Federal Government: $9,961

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]? No

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: 05/28/2010

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