September 11th Victim Compensation Fund Claimant Registration Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OMB Number 1123-00 PI Eligibility Form Final	Form and Instruction	Modified	Available
Form OMB Number 1123-00 PI Compensation Form	Form and Instruction	Modified	Available
Form OMB Number 1123-00 Deceased Eligibility Form	Form and Instruction	Modified	Repair queued
Form OMB Number 1123-00 Deceased Compensation Form	Form and Instruction	Modified	Available
Justification for Emergency Approval Request -- Eligibility and Compensation.docx	Supplementary Document	Uploaded 2011-10-28	Available
Justification for Emergency Approval Request 9 28 11.doc	Supplementary Document	Uploaded 2011-09-29	Available
83i PRA_092611.pdf	Supplementary Document	Uploaded 2011-09-26	Available
0070.pdf	Supplementary Document	Uploaded 2011-09-26	Available
0066-2.pdf	Supplementary Document	Uploaded 2011-09-26	Available
0066-1.pdf	Supplementary Document	Uploaded 2011-09-26	Available
0056.pdf	Supplementary Document	Uploaded 2011-09-26	Available
Supplementary document_0028.pdf	Supplementary Document	Uploaded 2011-09-26	Available
supplementary document_0041.pdf	Supplementary Document	Uploaded 2011-09-26	Available
Supporting Statement PRA -- Eligibility and Compensation Form - updated 10.28.11.docx	Supporting Statement A	Uploaded 2011-10-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Modified	PI Eligibility Form Final
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Modified	PI Compensation Form
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Modified	Deceased Eligibility Form
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Modified	Deceased Compensation Form
199461	September 11th Victim Compensation Registration Form	Other-Screen Shots	Modified

ICR Details

OMB Control No: 1105-0092	ICR Reference No: 201201-1105-002
Status: Historical Active	Previous ICR Reference No: 201109-1123-001
Agency/Subagency: DOJ/LA	Agency Tracking No:
Title: September 11th Victim Compensation Fund Claimant Registration Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/28/2011
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/12/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/12/2012
Terms of Clearance: For the renewal of this package, DOJ will break the burden up by form in ROCIS.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2012	6 Months From Approved
Responses	70,000	0	70,000
Time Burden (Hours)	700,000	0	23,100
Cost Burden (Dollars)	0	0	0

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Abstract: Under the James Zadroga September 11 Health and Compensation Act of 2010 (P.L. 111-347), the Department of Justice would request biographical information and limited information regarding eligibility for the September 11th Victim Compensation Fund from potential claimants in order to begin the process of determining whether claimants will be eligible for compensation from the Fund.

Emergency Justfication: Justification for Emergency Approval Request Emergency approval of the September 11th Victim Compensation Fund Claimant Eligibility and Compensation Form is requested given the high-profile and time-sensitive nature of this program. The Final Rule governing the administration of the Fund, which was published in the Federal Register on August 31, 2011, was effective October 3, and claimants have begun to register for the Fund. Emergency approval is needed in order to begin processing compensation claims as soon as possible. Absent emergency approval, eligible claimants would have to wait substantially longer to begin filing their claims, thereby impairing Congress’s goal of providing compensation in as expeditious a manner as possible (as evidenced by the short statutory deadline for implementation). Such a delay in implementing the compensation process would clearly be contrary to the public interest. In addition, delaying the publication of the forms associated with the Victim Compensation Fund will prevent the Department from accomplishing its stated goal of allowing victims to begin to submit claims in October 2011. Meeting this date is consistent with the priorities of the Administration and the Fund’s Special Master. Timeline The following timeline is based on receiving emergency approval of the form. October 28, 2011 Make Eligibility Form available to the public. Late November 2011 Make Compensation Form available to the public

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Authorizing Statute(s): PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1105-AB39	Final or interim final rulemaking	76 FR 54112	08/31/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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
September 11th Victim Compensation Registration Form	OMB Number 1123-0012, OMB Number 1123-0012, OMB Number 1123-0012, OMB Number 1123-0012	Deceased Compensation Form ,   Deceased Eligibility Form ,   PI Compensation Form ,   PI Eligibility Form Final

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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	70,000	70,000	0	0	0	0
Annual Time Burden (Hours)	700,000	23,100	0	676,900	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: An adjustment made to the calculations.

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Annual Cost to Federal Government:

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: 10/28/2011

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