Supporting Statement
Claim for Continuance of Compensation (CA-12)
OMB NO. 1240-0015
A. Justification
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 Office of Workers’ Compensation Programs administers the Federal Employees’ Compensation Act, 5 USC 8101 et seq. Under section 8133 of the Act, eligible dependents of deceased employees receive compensation benefits on account of the employee's death. OWCP has to monitor death benefits for current marital status, potential for dual benefits, and other criteria for qualifying as a dependent under the law. The CA-12 is sent annually to beneficiaries in death cases to ensure that their status has not changed and that they remain entitled to benefits. In most cases, it is a matter of ensuring that a surviving spouse or child is still living and has not married so as to make them ineligible. The CA-12 is established for this purpose under 20 CFR 10.414. Reference:
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 provided is used by OWCP claims examiners to ensure that death benefits being paid are correct, and that payments are not made to ineligible survivors.
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 Form CA-12 is available on-line in a PDF fillable and printable format at
http://www.dol.gov/owcp/regs/compliance/ca-12.pdf.
The CA-12 can also be accessed through DOL’s DFEC on-line forms library at http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm.
However, even though technology for automated collection of this information is currently available, this form is initiated by the Government Agency (OWCP), not by the general public and it can require multiple signatures from different private and or public entities and therefore should not be made available for electronic submission.
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 A.2 above.
The information requested on the Form CA-12 is not duplicative of any information available elsewhere. The claimant/beneficiary is the only source of this information.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
This information collection does not have a significant 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.
This form is sent once a year in each case where death benefits are being paid. If the information were not collected, or were collected less frequently, individuals who were no longer entitled to death benefits would receive those benefits, thereby creating overpayments of compensation.
7. Explain any special circumstances.
There are no special circumstances for conducting this information collection.
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.
A Federal Register Notice inviting comment on this collection of information was published in the Federal Register on March 4, 2014 [79FR12225]. No comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
Respondents do not receive any gifts or payments to furnish the requested information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations or agency policy.
All information contained in FECA claim files is fully protected under the Privacy Act in the system of records known as DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal Employees' Compensation Act File).
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.
The request to supply social security number information would be considered sensitive, but receipt of this number by OWCP is essential in properly determining entitlement to benefits under the Act.
12. 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 are 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. Provide estimates of the hour burden of the collection of information.
The CA-12 requires the respondent to provide the information on his or her marital status, as well as the marital and educational status of any dependent children. The respondent is able to simply fill out the form immediately, since the information requested would not require any research. Past experience with the use of this form indicates that it will take approximately 5 minutes for each respondent to provide the information that is requested.
Based on actual usage, it is estimated that 4,083 forms will be used annually. At 5 minutes per form, that is 1/12 or .083 of an hour-- .083 X 4083 = 338.89 or 339 hours, rounded up. This number is based on the 3 year averages from June 2011 - June 2013 of eligible beneficiaries in receipt of death benefits.
Because the wage category of most of the respondents is not known, we have estimated the cost of the burden hours using the National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS, or $20.27 per hour.
$20.27 X 340 hours = $6,871.53 ($6,872 rounded up) respondent cost.
http://data.bls.gov/pdq/SurveyOutputServlet
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
Operating
and maintenance costs consist of the price of postage to return the
form. $.49 X 4, 083 =
$2,000.67
or $2,001, rounded up.
14. Provide estimates of annualized cost to the Federal government.
Time to review each form - 1/12 = .083 of an hour
Hourly wage of reviewer - $38.85 (GS-12/6)
http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2014/salhrl.pdf
4,083 X $38.85 X .083 = $13,165.84 ($13,166 rounded up) = processing costs
Processing Cost - $13,166.00
Mailing Costs - 2,001.00
Total - $15,167.00
15. Explain the reasons for any program changes or adjustments reported in ROCIS.
There are currently 4,083 individuals receiving death benefits vs. 4,570, which were reported in the previous OMB submission, a difference of 487 respondents. The annual Information Collection Time Burden (hours) is 339, which is a decrease of 40 hours based on the previous reporting hours of 379. The operation and maintenance costs associated with this submission is $2001 (a decrease of $10.00 from the previous figures of $2011) due to decreases in the number of respondents.
The instructions and questions on the form have been revised to comply with current federal law and FECA Bulletin No. 14-01, December 12, 2013. This change impacts augmented compensation, survivor benefits, death gratuity, schedule awards unpaid at death, and other DFEC administered benefits.
In the certification part of the form, two changes were made. The form asks for signature of the claimant which was changed to beneficiary. Where the beneficiary signs by a mark (“X”), the revised form now requires two witnesses.
Finally, an accommodation statement was placed on the form to inform claimants who have mental or physical limitations to contact DFEC for if further assistance is needed in the claims process.
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.
The information collected with this form 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 display of the expiration date is sought.
18. Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to certification.
B. Collections of Information Employing Statistical Methods
This information collection does not employ statistical methods.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | US Department of Labor |
| Last Modified By | yferguso |
| File Modified | 2014-03-14 |
| File Created | 2014-03-14 |