Contractor Surveys under the Federal Employees’ Compensation Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
amendment summary of changes.doc	Supplementary Document	Uploaded 2010-10-27	Available
VPAT_SurveyMonkey.pdf	Supplementary Document	Uploaded 2010-06-01	Available
revised supporting statement b- sep24 (2).doc	Supporting Statement B	Uploaded 2010-09-27	Available
final supporting statement 10-19 (3).doc	Supporting Statement A	Uploaded 2010-10-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192950	Contractor-Rehabilitation Counselor Survey	Other-survey	New
192949	Contractor Survey-Field Nurse Survey	Instruction	New
192948	Contractor Survey-COP Nurse	Other-survey	New

ICR Details

OMB Control No: 1240-0052	ICR Reference No: 201005-1240-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Contractor Surveys under the Federal Employees’ Compensation Act
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/05/2010
	Date Received in OIRA: 10/04/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2013	36 Months From Approved
Responses	330	0	0
Time Burden (Hours)	68	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: COP Nurses, Field Nurses, and Rehabilitation Counselors would respond to this information collection to provide input regarding program effectiveness that OWCP-DFEC would use as part of an impact evaluation assessing the quality and types of services being provided during the return to work period.

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Authorizing Statute(s): None

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 34768	06/18/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 61177	10/04/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Contractor Survey-COP Nurse
Contractor Survey-Field Nurse Survey
Contractor-Rehabilitation Counselor Survey

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ICR Summary of Burden

table that charts list 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	330	0	0	330	0	0
Annual Time Burden (Hours)	68	0	0	68	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: As part of its 2008 Performance Analysis Rating Tool (PART) evaluation by the Office of Management and Budget (OMB) of the FECA program, OMB directed DFEC to conduct an “Impact Evaluation” of program effectiveness. An impact evaluation measures the effectiveness of the program and the extent to which its goals were achieved. To comply with the OMB directive, DFEC designed a study to focus on the effectiveness of its Disability Management (DM) activities. DM consists of the delivery of services that include early intervention by nurses, coordination of medical care and management of the disability, and assistance with return to work, including vocational rehabilitation. DOL has awarded a contract for the evaluation. Objectives of the study include a mapping out of the DM conceptual framework, (including workflow, staff roles and responsibilities, and processes), measurement of performance results, and an assessment effective workings of DM procedures and the coordination and execution of roles of the Federal and contractor staff involved in DM.

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Annual Cost to Federal Government: $10,249

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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]? No

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: 10/04/2010

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