September 11th Victim Compensation Fund Claimant Registration Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form XXXX Deceased Compensatin Form	Form and Instruction	New	Available
Form XXXX Deceased Eligibility Form	Form and Instruction	New	Available
Form XXXX Personal Injury Compensatin Form	Form and Instruction	New	Available
Form XXXX Personal Injury Eligibility Form	Form and Instruction	New	Available
Form OMB Number 1123-00 PI Eligibility Form Final	Form and Instruction	Removed	Available
Form OMB Number 1123-00 PI Compensation Form	Form and Instruction	Removed	Available
Form OMB Number 1123-00 Deceased Eligibility Form	Form and Instruction	Removed	Available
Form OMB Number 1123-00 Deceased Compensation Form	Form and Instruction	Removed	Available
83i PRA_092611.pdf	Supplementary Document	Uploaded 2011-09-26	Available
1105-0092_Supporting_Statement_PRA_--_Eligibility_and_Compensation_Form_-_updated_6_18_12.doc	Supporting Statement A	Uploaded 2012-06-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202770	Deceased Compensatin Form	Form and Instruction	New	Deceased Compensatin Form
202769	Deceased Eligibility Form	Form and Instruction	New	Deceased Eligibility Form
202768	Personal Injury Compensation Form	Form and Instruction	New	Personal Injury Compensatin Form
202767	Personal Injury Eligibility Form	Form and Instruction	New	Personal Injury Eligibility Form
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Removed	PI Eligibility Form Final
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Removed	PI Compensation Form
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Removed	Deceased Eligibility Form
199461	September 11th Victim Compensation Registration Form	Form and Instruction	Removed	Deceased Compensation Form
199461	September 11th Victim Compensation Registration Form	Other-Screen Shots	Removed

ICR Details

OMB Control No: 1105-0092	ICR Reference No: 201201-1105-003
Status: Historical Active	Previous ICR Reference No: 201201-1105-002
Agency/Subagency: DOJ/LA	Agency Tracking No:
Title: September 11th Victim Compensation Fund Claimant Registration Form
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 without change	Conclusion Date: 07/07/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/18/2012
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	70,000	0	70,000
Time Burden (Hours)	700,000	0	700,000
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.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 5056	02/01/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 21107	04/09/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Deceased Compensatin Form	XXXX	Deceased Compensatin Form
Deceased Eligibility Form	XXXX	Deceased Eligibility Form
Personal Injury Compensation Form	XXXX	Personal Injury Compensatin Form
Personal Injury Eligibility Form	XXXX	Personal Injury Eligibility Form
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	700,000	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There is no burden change. Burden is broken down by IC for this ICR, consistent with previous terms of clearance.

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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: 04/18/2012

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