Ri 30-10 Ss

OMB SUPPORTING STATEMENT

RI 30-10 – Disabled Dependent Questionnaire

A. Justification

1. Title 5, U. S. Code, Sections 8341(a)(4)(B) and 8441(4)(B) provide survivor benefits for unmarried, dependent children, regardless of age, who are incapable of self-support because of mental or physical disability incurred before age 18. Section 8901(5)(B), which defines the family members who are eligible for health benefits coverage, includes any unmarried, dependent children, regardless of age, who are incapable of self-support because of mental or physical disability which existed before age 22. RI 30-10 is designed to collect information about the disabled child’s ability to earn a living and to obtain medical facts about the disability.

2. The information collected is used by the Office of Personnel Management (OPM) to determine whether to pay benefits and include the individual as a family member for health benefits coverage. The person applying is asked about the disabled person’s wage-earning capability, and the attending physician is asked to describe the disability and give other information about the disability and its effect on the person’s ability to make a living. If the information is not collected, OPM cannot determine eligibility or pay benefits, as required by law. The Public Burden Statement meets the requirements of 5 CFR 1320.8(b)(3).

3. The information collected is detailed and can only be obtained from the respondents.

New methods of information technology would do little to reduce the burden on the

respondents; they must sign the questionnaire and take it to their physician. However,

this form is available on our website in a pdf fillable format and meets our GPEA

requirements.

4. The questionnaires are filed individually because there is no other way to obtain this information. Duplication is minimized.

5. Information is not collected from small businesses.

6. This information collection is performed as needed to pay benefits or enroll eligible persons. Less frequent collection would delay the payment of survivor annuities or health benefits enrollment provided by law.

7. The collection is consistent with the guidelines in 5 CFR 1320.6.

8. A notice of proposed information collection was published in the Federal Register on April 5, 2011, giving persons outside the agency an opportunity to comment on the form. No comments were received.

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9. No payment or gift is provided to the respondents.

10. This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses for disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008).

11. The information collection does not include questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. However, RI 30-10 does collect information regarding the disabled child’s medical condition. The information is needed so that OPM can determine whether the child is disabled within the meaning of the law. The respondent is aware that OPM needs the medical documentation and assists in the transaction by taking the RI 30-10 to the child’s physician to obtain the required medical documentation.

12. Approximately 2,500 Disabled Dependent Questionnaires will be processed each year. RI 30-10 requires approximately 60 minutes to fill out. The annual burden of 2,500 hours is estimated.

13. We estimate that respondents pay $100 to $150 to obtain needed medical records and physician’s statements. They do not necessarily have to get a special medical evaluation to fulfill the OPM requirements.

14. The annualized cost to the Federal government is $7,725. This cost was determined by employee salary hours devoted to the program, forms cost, and overhead.

15. There are no changes to the respondent burden.

16. The results of this information collection are not published.

17. It is not cost effective to reprint the whole supply of forms to change the OMB clearance expiration date. Therefore, we seek approval not to display the date on the form.

18. There are no exceptions to the certification statement.