Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

Forms and Documents

Document Name	Status
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction	Modified
dol-govt-1.doc Supplementary Document	2013-06-13
SS 8147 Employees Compensation Fund.doc Supplementary Document	2013-06-13
CFR-2010-title20-vol1-sec61-101.pdf Supplementary Document	2013-06-13
CFR-2010-title20-vol1-sec61-104.pdf Supplementary Document	2013-06-13
2012 Employment Wages for Insurance Claims and Policy Processing Clerks.doc Supplementary Document	2013-06-13
2013 OPM Salary Table-Cleveland.pdf Supplementary Document	2013-06-13
Supporting Stmt OMB 1240-0006.docx Supporting Statement A	2013-10-21

IC Document Collections

IC ID	Document Title	Status
13940	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0006	ICR Reference No: 201306-1240-002
Status: Historical Active	Previous ICR Reference No: 201005-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
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: 12/27/2013
	Date Received in OIRA: 10/29/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved	12/31/2013
Responses	393	0	269
Time Burden (Hours)	197	0	135
Cost Burden (Dollars)	1,407	0	557

---

Abstract: Information collected using Form CA-278 will allow OWCP to consider requests filed by insurance carriers and self-insured that have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees' Compensation Fund.

---

Authorizing Statute(s): US Code: 5 USC 8147 Name of Law: The Federal Employees' Compensation Act
   US Code: 42 USC 1701 Name of Law: War Hazards Compensation Act (WHCA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 40514	07/05/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 64536	10/29/2013
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	CA-278	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

---

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	393	269	0	0	124	0
Annual Time Burden (Hours)	197	135	0	0	62	0
Annual Cost Burden (Dollars)	1,407	557	0	0	850	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 previous approved number of annual respondents 269 is now 393, which represents an increase of 124. The previously approved number for burden hours was 135, and the requested number now is 197, an increase of $62.00. The costs burden for maintenance and reporting costs (postage and envelope) increased from $557 to $1,407, which is an adjustment of $850.00. Additionally, form was revised to include an accommodation statement to inform claimants who have mental or physical limitations to contact DFEC if further assistance is needed with the claims process.

---

Annual Cost to Federal Government: $10,053

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

---

Common Form ICR:  No

---

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: 10/29/2013

---