OMB_-_Supporting_Statement_for_1240-0040_(LS-265)_(20110228)

SUPPORTING STATEMENT

Certification of Funeral Expenses

(LS-265)

OMB No. 1240-0040 (Formerly 1215-0027)

A. Justification.

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 Office of Workers' Compensation Programs administers the

Longshore and Harbor Workers' Compensation Act. The Act provides benefits to workers injured in maritime employment on the navigable waters of the United States or in an adjoining area customarily used by an employer in loading, unloading, repairing, or building a vessel. In addition, several acts extend Longshore Act coverage to certain other employees.

Section 9(a) of the Act provides that reasonable funeral expenses not to exceed $3,000 shall be paid in all compensable death cases. Form LS-265 has been provided for use in submitting the funeral expenses for payment.

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.

The form is submitted to OWCP district offices that have responsibility for monitoring and processing death cases. The information is usually incorporated into a compensation order at the time death benefits are ordered paid in a case. It is used to certify the amount of funeral expenses incurred in the case. If the information were not collected, we would be unable to determine the amount of funeral expenses that should be paid.

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.

In accordance with the Government Paperwork Elimination Act (GPEA), it is neither practicable nor cost effective to make Form LS-265 electronically interactive considering the relatively small amount of responses annually and the likelihood of the respondent universe to use the electronic option. However, while the form is not available for electronic submission it is available on DOL’s website for completion online, printing and downloading. The website for accessing this document is http://www.dol.gov/owcp/dlhwc/ls-265.pdf.

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.

All forms in the Longshore program have been carefully reviewed to eliminate all requests for duplicate information. The LS-265 is a unique form in that it pertains to the certification of funeral expenses.

5. If the collection information impacts small businesses or other small entities (Item 5 of 014B Form 83-1), describe any methods used to minimize burden.

The collection does not have a significant economic impact on a substantial number of small businesses.

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 only collected on occasion when certification of funeral expenses is required. It therefore cannot be collected less frequently.

7. Explain any special circumstances.

There are no special circumstances for the collection of this information.

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.

The LS-265 has been in use for a number of years and no complaints have been received relative to the information it requests. It requests only basic information relative to the amount of funeral expenses incurred and only a small number of copies are used each year. Should any suggestions for improvement be received, they will be reviewed and appropriate action will be taken.

A Federal Register Notice inviting public comment on this collection of information was published in the Federal Register on October 18, 2010. 75 Fed. Reg. 63862. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments 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.

Records pertaining to compensation cases are covered under the Privacy Act. The system names Office of Workers’ Compensation Programs, Longshore and Harbor Workers’ Compensation Act case files.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, 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.

There are no 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.

Burden has been estimated to be approximately 20 hours. It is estimated that about 80 funeral directors will file approximately one form each for a total annual number of forms filed of 80. The source for the estimates is derived from the actual number of forms received annually. The time needed to complete the form, including the time needed to obtain the information required by the form from existing records, has been estimated to be 15 minutes or .25 hours. This estimate is considered reasonable in light of the information required by the form, which is the amount of services rendered which is readily available to the funeral director.

The annualized burden cost to the respondents has been estimated to be approximately $306.20. This estimate is derived from use of the National Average Weekly Wage (NAWW) as computed by the Bureau of Labor Statistics and which is based on the national average earnings of production or non-supervisory workers on private non-agriculture payrolls. Section 6(b) of the Act mandates the use of the NAWW in setting the maximum and minimum compensation rates under the Act and in determining the amount of annual adjustments due to permanent total disability and death beneficiaries. While the form is filed on behalf of funeral directors, the form may be completed by employees in the administrative office or by other clerical personnel. Since it is not possible to determine the specific occupation or wages for each person who will provide the information covered by this clearance, and wages can vary considerably from person to person depending on duties and length of service, use of a national average weekly wage covering all occupations appears reasonable under the circumstances.

The current applicable NAWW is $612.33. The computations are therefore as follows:

$612.33  40 hrs = $15.31/hr

$15.31 x 20 hrs = $306.20 annualized burden cost.

13. Annual Costs to Respondents (capital/start-up & operation and maintenance)

Since the information required by Form LS-265 is kept as a usual and customary business practice, the only operation and maintenance cost for this information is for mailing. The cost is therefore approximately $37.60 (80 responses x $.44 postage + $.03 envelope).

14. Provide estimates of annualized cost to the Federal government.

The cost to the government has been estimated to be approximately $253.11. This estimate was determined by taking into consideration printing, distribution and analysis costs associated with the issuance and review of Form LS-265. Printing costs were determined by using a cost of $2.25 per 100 copies for a one-sided form. Distribution costs were determined by applying the postage (.44 cents) and envelope charge (.03 cents) against the number of copies issued. Analysis and handling costs were determined by applying the hourly rate of a GS-12 claims examiner (currently $32.97 hour) to the total annual hours required for review. The annual review hours were determined by applying an estimate of .08 hour or 5 minutes for review and analysis of each form against the 80 forms, which are received each year. The calculations are as follows:

Printing $ 4.50 ($2.25 x 2)

Distribution 37.60 (80 x .47)

Analysis 211.01 (80 x .08 = 6.4 hours x $32.97)

Total $253.11

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

Burden had decreased from 49 to 20 due to a reduction in the actual forms submitted this past year. DOL has updated Form LS-265 to update the OMB Control Number, reflecting a DOL reorganization that dissolved the former Employment Standards Administration into its constituent programs and to enhance the disclosure of the information collection burden and the public protection notice. Upon OMB’s clearance of this request OWCP will update the form to show the new expiration date.

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.

The information collected will not be published for statistical use.

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 expiration date will be displayed on the form.

18. Explain each exception to the certification statement identified in Item 19 "Certification for Paperwork Reduction Act”.

There are no exceptions to the certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

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