Death Gratuity Forms Supporting Statement 1-14-10_revised

SUPPORTING STATEMENT

Death Gratuity Forms

CA-40, CA-41 and CA-42 (Formerly 1215-0206)

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 National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of P.L. 110-181 amended the Federal Employees’ Compensation Act (FECA) creating a new section, 5 U.S.C. §8102a effective upon enactment. This section establishes a new FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation. 5 U.S.C.§8102a also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001 in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom.

Form CA-40 requests the information necessary from the employee to accomplish this variance. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

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 information collected through forms CA-40, CA-41 and CA-42 is used by claims examiners in OWCP to determine a person’s entitlement to any or all of the death gratuity payment provided by 5 U.S.C.§8102a.

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), the Division of Federal Employees’ Compensation seeks to allow individuals and entities that deal with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate.

The forms will be available via through the following website in a PDF fillable and printable format in accordance with the GPEA.

http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

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.

The information requested in these collections is not duplicative of any information available elsewhere in OWCP or in any other Federal executive agency. The beneficiary classes under this benefit program are different than under any other FECA benefit and also cover NAFI employees, which have previously never been covered under FECA. The respondents are the only source of all the required information.

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.

This information collection has been streamlined to obtain the necessary information while imposing the minimum burden on the respondent. This information collection does not have a significant economic impact on a substantial number of small entities.

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.

If this information were not collected, OWCP would be unable to administer and provide the death gratuity to the appropriate beneficiaries, as required by the statute.

7. Explain any special circumstance.

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 last Federal Register Notice inviting comment (under the former OMB Control No. 1215-0206) was published January 28, 2010. No comments were received.

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

The decision to provide a payment to a respondent is a decision on entitlement to death gratuity benefits under the FECA by OWCP.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

The information collected by these requests is maintained in FECA claim files, which are fully protected under the Privacy Act. Records pertaining to compensation cases are covered under the Privacy Act. The Privacy Act Notice is provided on each of the forms. All forms used to initiate a compensation claim contain a statement advising the claimant of the revisions of the Privacy Act. The applicable Privacy Act system of records is called DOL/GOVT-1. See Web site:

http://www.dol.gov/sol/privacy/dol-govt-1.htm.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered 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.

No questions regarding sexual behavior, religious beliefs, etc. are asked by the CA-40, CA-41 or CA-42.

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.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

The following chart shows the projected burden hours for this collection. The total number of respondents is estimated to be 2,600 for the CA-40, 25 for the CA-41, and 10 for the CA-42. There are 2,625 individual respondents and 10 government agency respondents. These figures are derived from the number of federal employees deployed oversees, and the number of federal employee fatalities that have occurred in connection with contingency operations since October of 2001. Each estimate represents the average time it takes one respondent to complete one response.

Form	Time to Complete	Frequency of Response	Number of Respondents	Number of Responses	Hours Burden
CA-40 Individual Respondent	15 min.	1	2,600	2,600	650
CA-41 Individual Respondent	15 min.	1	25	25	6.25
CA-42 Agency Respondent	20 min.	1	10	10	3.33
Totals			2,635	2,635	659.58

The combined burden hours have been calculated to be 659.58. Because the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage for production or non-supervisory workers on private nonagricultural payrolls as computed by BLS, or $18.73 per hour.  $18.73 X 659.58 hours = 12, 353.93 or rounded $12, 354. Reference: ftp://ftp.bls.gov/pub/suppl/empsit.ceseeb2.txt (as of October 2009)

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

Because the information requested from individual respondents will be readily known, there are no capital/start-up costs. Furthermore, as the Form CA-40 will normally be filled out and given to the employing agency with the normal deployment package, there should be no annual cost to the individual respondents for this form. Therefore, the only actual cost the respondents must bear is the cost of mailing the Form CA-41.

The mailing costs are calculated as follows:

Total claimant costs Forms CA-41

[$0.44 (postage) + $0.03 (envelopes)] x 25 (forms) =$11.75 (or $12.00 rounded up).

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

Review Costs: The average hourly wage for the reviewer is that of a GS-11/1, $27.03 per hour (Federal Salary Table for Rest of US, 2009). https://www.opm.gov/oca/09tables/pdf/rus_h.pdf

Form	Time to Review	Total Respondents	Costs
CA-40	30 minutes	2600	$35,139
CA-41	30 minutes	25	$337.88
CA-42	30 minutes	10	$135.15
Total Review Costs			$35,612

Federal Cost Estimates:

Printing Cost: There will be no printing cost since the CA-40, CA-41 and CA-42 will only be stored in OWCP’s ADP systems in a word processing program

Mailing and Envelope Cost: The CA-41 is the only form that will require mailing and postage-- $0.44 (postage) + $0.03 (envelope) X 25 = $11.75 or $12.00 rounded up.

Total Federal Cost: $35, 612 (review costs + $12.00 (postage)) = $35,624

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

There are no program changes or adjustments in Items 13 or 14.

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.

Data collected by the CA-40, CA-41 and CA-42 will not be published.

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.

No exception to the display of the expiration date is sought.

18. Explain each exception to the certification statement identified in Item "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

This request is in compliance with 5 CFR 1320.9

1. Collections of Information Employing Statistical Methods:

Not applicable.

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