TSA Claims Management System

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SF 95 TSA Claims Management System	Form	Modified	Available
30_Day_FR_Notice.pdf	Supplementary Document	Uploaded 2011-11-21	Available
60-Day Notice.pdf	Supplementary Document	Uploaded 2011-11-16	Available
Sample Letters.pdf	Supplementary Document	Uploaded 2009-11-10	Available
CMS Screen Shots.doc	Supplementary Document	Uploaded 2009-08-24	Available
CMS_Supporting Statement.docx	Supporting Statement A	Uploaded 2012-07-02	Available
SF95.pdf	Supplementary Document	Uploaded 2009-08-21	Available
Federal Tort Claims Act.pdf	Supplementary Document	Uploaded 2009-08-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43964	TSA Claims Management System	Form	Modified

ICR Details

OMB Control No: 1652-0039	ICR Reference No: 201111-1652-006
Status: Historical Active	Previous ICR Reference No: 200904-1652-002
Agency/Subagency: DHS/TSA	Agency Tracking No: 1652-0039
Title: TSA Claims Management System
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 with change	Conclusion Date: 07/07/2012
	Date Received in OIRA: 11/29/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	36 Months From Approved	07/31/2012
Responses	12,000	0	22,800
Time Burden (Hours)	6,000	0	11,400
Cost Burden (Dollars)	17,760	0	8,900

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Abstract: TSA Claims Management Branch (CMB) requests to continue collection of certain information to investigate tort claims filed against TSA for property damage, property loss, personal injury, or death. TSA needs to collect certain information from claimants, in addition to that collected on the Standard Form 95, to investigate claims properly. TSA is seeking continued approval for two forms associated with this process.

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Authorizing Statute(s): US Code: 28 USC 1346(b), 1402(b), 2401(b), Name of Law: Federal Tort Claims Act
  

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:
	76 FR 16799	03/25/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 71993	11/21/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
TSA Claims Management System	SF 95	Claim for Damage Injury or Death

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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	12,000	22,800	0	0	-10,800	0
Annual Time Burden (Hours)	6,000	11,400	0	0	-5,400	0
Annual Cost Burden (Dollars)	17,760	8,900	0	0	8,860	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: There has been a decrease in number of respondents due to the reduction of claims submitted.

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Annual Cost to Federal Government: $500,000

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]? 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: 11/29/2011

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