Request for Employment Information

Forms and Documents

Document Name	Status
Form ca-1027 Request for Employment Information Form and Instruction	Modified
Section 8106.doc Supplementary Document	2012-09-18
OPM Salary Table 2012-rus.pdf Supplementary Document	2012-09-18
tableb2_201201.pdf Supplementary Document	2012-09-18
ss 1240-0047 2012.docx Supporting Statement A	2012-11-01

IC Document Collections

IC ID	Document Title	Status
13773	Request for Employment Information Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0047	ICR Reference No: 201209-1240-004
Status: Historical Active	Previous ICR Reference No: 201003-1240-047
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Employment Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/24/2013
	Date Received in OIRA: 12/11/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	01/31/2013
Responses	431	0	500
Time Burden (Hours)	108	0	125
Cost Burden (Dollars)	207	0	235

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Abstract: This information collection is used to collect information about a claimant's employment. It is necessary to determine continued eligibility for compensation payments under FECA.

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Authorizing Statute(s): US Code: 5 USC 8106 Name of Law: Federal Employees' Compensation 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:
	77 FR 52764	08/30/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 73683	12/11/2012
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Request for Employment Information	ca-1027	Request for Employer Information

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ICR Summary 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	431	500	0	0	-69	0
Annual Time Burden (Hours)	108	125	0	0	-17	0
Annual Cost Burden (Dollars)	207	235	0	0	-28	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: The adjustments are resultant from a decrease in the number of claims for wage loss filed by former federal employees in which earnings information is sought from a private employer. While not affecting burden, this ICR has been classified as a revision because of added language to Form CA-1027 on the rights of persons with disabilities.

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Annual Cost to Federal Government: $5,357

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: 12/11/2012

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