OMB - Supporting Statement for 1240-0014 - 513 changes 11-19-13

SUPPORTING STATEMENT

ADMINISTRATION OF THE LONGSHORE

AND HARBOR WORKERS’ COMPENSATION ACT

OMB No. 1240-0014

(Formerly 1215-0160)

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 (OWCP) administers the Longshore and Harbor Workers' Compensation Act (LHWCA). LHWCA provides benefits to workers injured in maritime employment on the navigable waters of the United States or in an adjoining area customarily used by an employer in loading, unloading, repairing, or building a vessel. In addition, several Acts extend the Longshore Act's coverage to certain other employees.

The Secretary of Labor has authority to make rules and regulations to establish procedures which are necessary or appropriate to carry out the provisions of the Act. 33 U.S.C. §§ 939, 944. The Secretary has delegated that authority to the Director, Office of Workers’ Compensation Programs. Secretary’s Order 10–2009; Pub. L. 111–5 § 803, 123 Stat. 115, 187 (2009).

A claimant's social security number may be requested pursuant to Public Law 103-112 and the regulations at 20 CFR 702.202 and 702.221.

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 following regulations have been developed to implement the Act's provisions and to provide clarification in those areas where it was deemed necessary. In some cases, prior regulations have been updated and changed to either reflect the intent of the amended Act or to correct recognized deficiencies.

20 CFR 702.162 -- This section pertains to the payment of compensation liens acquired by trust funds which comply with section 302(c) of the Labor - Management Relations Act of 1947, 29 U.S.C. 186(c) (LMRA), and which are established pursuant to a collective bargaining agreement in effect between an employer and an employee entitled to compensation under the Act. To establish entitlement to a lien, the District Director or Administrative Law Judge may require that certain information be submitted, e.g., a copy of the trust agreement, a copy of the collective bargaining agreement, and a certified statement showing the total amount of disability payments paid to the claimant. The information is needed to determine whether the trust fund is entitled to a lien pursuant to Section 17 of the Act.

20 CFR 702.174 and 702.175 -- These sections pertain to the certification of exemption and reinstatement of employers who are engaged in the building, repairing or dismantling of exclusively small vessels. Once certified, injuries sustained at the exempt facilities are not covered under the Act except under certain defined circumstances. Section 702.174 contains the information which must be submitted to obtain a certificate of exemption from the Director, OWCP. Section 702.175 sets forth the information which must be submitted to be reinstated should the exemption terminate for some reason. The information submitted is needed by the Director to determine whether an applicant meets the certification requirements contained in Section 3(d) of the Act. If the information were not collected, certification could not be granted under the Act.

20 CFR 702.242 -- This section pertains to the settlement of cases under the Act and the information which must be submitted in support of a settlement application. The information is submitted by the parties to the settlement to the District Director or Administrative Law Judge for evaluation and approval/disapproval. The information which is required is needed to properly evaluate the application to determine whether the proposed settlement is adequate. If the information were not submitted, there would be no basis for evaluating the proposal as required by Section 8(i) of the Act.

20 CFR 702.285 -- This section pertains to the reporting of earnings by injured claimants receiving compensation benefits under the Act. The section implements Section 8(j) of the Act, which gives authority to employers and insurance carriers to collect earnings information from claimants to whom they are paying compensation benefits. The earnings reports may be requested semi-annually. The information will be used by employers and self-insurers to determine whether benefits they are paying claimants should be reduced based on earnings received. In addition, the Director (OWCP) may request earnings information from those claimants who are receiving benefits from the Special Fund. A form has been developed to collect the earnings information, Form LS- 200, Report of Earnings, and is attached as part of this clearance request. If the information were not collected, claimants may continue to receive compensation benefits which they may not be entitled to receive.

20 CFR 702.321 -- This section pertains to the filing of an application for relief with a District Director under Section 8(f) of the Act. Section 8(f) contains the second injury provisions of the Act which serve to reduce an employer's liability for compensation payments in those cases in which the disability incurred as a result of an injury is greater due to prior disabilities which have been sustained. In those cases in which section 8(f) relief is granted, the employer/carrier generally will pay only 104 weeks of permanent disability payments with the remainder of payments due being paid from the Special Fund authorized under Section 44 of the Act. The Act requires that all requests for 8(f) relief must first be presented to an OWCP deputy commissioner. The information required by this section is needed in order to properly evaluate the merits of the employer/carrier's request for 8(f) relief. If the information were not submitted, a proper evaluation of the application could not be made.

Individual forms used to collect/record information for claims adjudication under LHWCA are described below.

ESA-100 [(20 CFR 702.201), (702.111)]: This clearance pertains to the maintenance of injury reports under the Act. In compliance with current OSHA injury recordkeeping, it is a recordkeeping requirement instead of an actual form and requires employers to keep a record of and report on employees who have sustained injury or death under the Act whether loss time or not.

LS-271: Section 32(a) of the LHWCA requires that every employer shall secure the payment of compensation through either an authorized insurance company or by qualifying as a self-insured employer. To secure authorization to self-insure benefits under the Act or its extensions, the employer must submit Form LS-271, Application for Self-Insurance, which requests basic information concerning the applicant's type of business, number of employees, accident experience, type of excess insurance coverage, etc. The information that is collected is used by the OWCP to evaluate the qualifications of a company to self-insure its liability under the Act and extensions. It is also used to determine the amount of security a company must deposit with the OWCP to secure the prompt and continued payment of benefits under the Act. If the information were not collected, self-insurance authorizations could not be granted as required by the statute.

LS-274: 20 CFR 703.310 of the Regulations Governing the Administration of the Longshore and Harbor Workers’ Compensation Act and its extensions requires that insurance carriers and self-insured employers authorized under the Act provide to the OWCP on request a report showing all outstanding injury and death cases and the particulars of each case. Form LS-274 is used for this purpose. The information contained on the form is used to evaluate the adequacy of the amount of negotiable securities or bond an insurance carrier or self-insurer is required to deposit with the OWCP to provide security for the payment of all outstanding obligations. The information collected is used by the National Office of the Division of Longshore and Harbor Workers’ Compensation to evaluate the adequacy of an insurance carrier or self-insurer’s security deposit relative to the outstanding liabilities for the company. If the information were not collected, there would be no way to determine whether an insurance carrier or self-insurer’s security deposit was adequate to provide for the continued payment of benefits of injured workers should the insurance carrier or self-insurer become insolvent or bankrupt.

LS-200: This form is used to verify whether the claimant earned any wages while also receiving compensation benefits. The claimant uses this form to report earnings for the previous year. If the information contained on the form were not collected, the Division would be unable to ascertain a claimant’s continued entitlement to compensation benefits.

LS-201: Under section 12 of the Longshore Act, an employee or beneficiary shall give written notice of injury or death within certain time frames as specified in the Act. Such notice is to be given to the District Director and the employer. Form LS-201 has been provided for this purpose. The information collected by Form LS-201 is used by employers/carriers to begin paying compensation benefits to injured claimants or their survivors and by the Longshore Division to establish a case file and to assure that claimants receive all the benefits under the Act to which they are entitled. If it is not submitted under certain circumstances, a claimant's right to compensation benefits could be denied.

LS-513: Section 44 of the Act requires that all insurance carriers and self-insurers authorized under the Act and/or extensions report to the Office of Workers' Compensation Programs each year the total amount of all payments made during the year under the Act and extensions. The reported payments are used to determine if a company is subject to an assessment under the Act. Form LS-513, Report of Payments, has been provided for this purpose. The information collected is used by the Longshore Division to determine the amount self-insurers and insurance carriers will be assessed each year for payment into the Special Fund. If the information were not collected, there would be no basis for determining the amount of a company's annual assessment. The detailed listing of claims submitted with the LS-513 is used internally and by external auditors to verify the figures reported, ensure the accuracy and reliability of the data collection and to ensure data integrity. Requiring submission of the contracting agency data for Defense Base Act cases is necessary to enable the Division to better cross-reference the information submitted on the LS-202 and adequately monitor DBA claims processing and compliance.

LS-267: This form is used to verify the continued entitlement of claimants to receive death benefits from the Special Fund. Specifically, the claimant, if receiving benefits as a surviving spouse, advises whether they have remarried since the prior reporting period or, if payments are being made on behalf of a beneficiary as a student, advises whether the beneficiary continues to be enrolled in school as a full-time student. If the information contained on the form were not collected, the Division would be unable to ascertain their continued entitlement to compensation benefits.

LS-203: This form is filed pursuant to section 13(a) of the Act and represents the injured employee's claim for compensation benefits. The form is completed by injured claimants and filed with our district offices. A copy of the form is forwarded by the district office to the employer/insurance carrier responsible for paying benefits to the claimant. If the information were not collected our district offices would have no way of determining the exact nature of a claimant's claim and whether the claimant is receiving all of the benefits that he/she is entitled to receive under the Act.

LS-204: This form is completed by physicians rendering treatment under the Act and is filed with the district office with a copy also sent to the responsible employer/insurance carrier. The form is needed to determine the medical progress of a case. If the information were not submitted, the district office would be unable to fulfill its medical monitoring obligation under Section 7 of the Act and would be unable to determine if claimants were receiving all benefits to which they are entitled.

LS-262: This form is used by all classes of dependents to file death claims under the Act. Such claims are required pursuant to section 13(a) of the Act. The completed claim forms are generally filed with our district offices which, in turn, forward copies to the responsible employers/carriers for investigation and processing. The information contained on the form is needed to determine eligibility for death benefits under the Act and if it were not collected, this determination could not be made.

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 LHWCA recognizes the requirement that all OMB forms (“when practicable”) were to be electronically interactive as of October 2003. The Forms LS-200, LS-201, LS-203, LS-204, LS-262, LS-267, LS-271, LS-274 and LS-513 can be downloaded from the DOL Internet site http://www.dol.gov/owcp/dlhwc/lsforms.htm.

For numerous reasons, including but not limited to those listed below, as well as the low volume of usage, the forms in this OMB package are not electronically interactive in accordance with GPEA. OWCP contends that this level of automation is not “practicable” for these forms.

LS-200 and LS-267 forms are not electronically interactive since multiple parties, e.g., the employer or insurance carrier, the claimant, and/or the Longshore Special Fund, must complete them. However, the forms are electronically fillable and printable.

LS-201 and LS-262 will not be electronically interactive due to the low number of forms received and limited benefit. However, the forms are electronically fillable and printable.

LS-203 and LS-204 will not be electronically interactive due to the lower volume and customer base, although it may be considered for electronic submission later. However, the forms are electronically fillable and printable.

LS-271 and LS-274 will not be electronically interactive because of the low number of forms received as well as the requirement for a corporate seal, notarization and numerous attachments. However, the forms are electronically fillable and printable.

LS-513 and the instructions relating to the form will be displayed on the internet, once approved. The form will not be available for electronic submission, but will be electronically fillable and printable. The supporting detailed listing of claims can be submitted electronically.

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.

All of the forms and regulations have been carefully reviewed to avoid duplication.

5. If the collection of information impacts small businesses or other small entities (Item 5 of 014B Form 83-1), describe any methods used to minimize burden.

Generally, the required information is collected from large employers who are self-insured under the Act or from large insurance carriers who are authorized to write insurance coverage under the Longshore Act. However, information is also requested from small businesses. To keep burden to a minimum, only that information which is considered absolutely essential to properly evaluate an application or determine entitlement to benefits is requested. This information collection does not have a significant economic impact on a substantial number of small businesses.

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.

The information required by the regulations and forms which are a part of this clearance is collected in accordance with the provisions of the Longshore Act. In administering a compensation program, information is generally submitted in the form of claims for benefits, medical documentation, and applications for specific authorizations or exemptions. The information is submitted on occasion, as the need arises, and therefore cannot be collected less frequently.

7. Explain any special circumstances.

The ESA-100 is not an actual form. It is a recordkeeping requirement in compliance with current OSHA recordkeeping (20 CFR 702.201) which requires employers to keep a record of and report on employees who sustain an injury or death under the Act whether the employee loses time or not.

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.

It should be noted that insurance carriers and self-insurers are in daily contact with our district offices where the forms are filed. We have received no complaints from these carriers and self-insurers relative to completion of the forms or the information that is required.

The DOL published a notice in the Federal Register on September 18, 2013 in Vol. 78, No. 181, Page 57416, inviting comments about this information collection. The agency received no comments in response to the notice.

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

No payments or gifts are provided to respondents.

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

To the extent information submitted is protected by the Privacy Act or the Trade Secrets Act, it is protected from disclosure except as provided under those statutes or otherwise provided by law.

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.

There are no questions of a sensitive nature.

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.

The burden estimates for all of the forms and sections of the regulations which come under this clearance are as follows:

LS-200, Report of Earnings (20 CFR 702.285):

Approximately 14,000 forms are expected to be received each year. It is estimated that in approximately 20 percent (or 2,800) of these cases, there will be no earnings information to report. The form has been designed to enable a claimant to merely check a box on the form showing that he has no earnings to report and to sign and return the form. The burden to the public has therefore been kept to a minimum and the burden associated with those reports containing no earnings has been classified as a certification and has been deleted from the burden estimate assigned to this form.

To determine the 14,000 responses, there are approximately 16,800 cases in compensation status at any given time under the Act and extensions, and approximately 18,200 new lost-time injuries are reported each year. It is estimated that the LS-200 will be used annually in approximately 40 percent of both the new injury cases reported and the cases in compensation status. An estimate of 40 percent has been used since compensation benefits will not be paid in all the newly reported compensation cases (some will be controverted), and compensation benefits will be paid for only short periods of time in other cases thereby not requiring the use of the LS-200 to verify earnings information. It is also estimated that in the majority of cases, there will be very little earnings to report. The 10 minute completion time should be viewed as an average completion time as substantially less than 10 minutes (.17 hour) will be required to complete the form if there are few earnings to report while a greater amount of time may be needed if there has been employment with one or more employers. The response time estimate takes into consideration such time that would be needed to check existing earnings or wage records and is considered reasonable under the circumstances. Burden is estimated to be 1,904 hours (.17 hours X 11,200 forms (expected to be completed each year which will contain earnings information)). Burden for this form is not affected by proposed changes made to LS-513.

20 CFR 702.162 (Liens)

Based on past experience since the last clearance, it is estimated that only 10 requests will be received each year to impose a lien on a claimant's compensation benefits pursuant to payments made by a trust fund authorized under this section. It has been estimated that it will take only 30 minutes (.5 hours) to furnish the information required by this section as only minimal information is required and this information is readily available. A copy of the collective bargaining agreement, the trust agreement, and a certified statement showing the total amount paid the claimant must be submitted. Total annual burden has estimated to be five (5) hours (.5 hours x 10 lien requests). Burden for this regulation is not affected by proposed changes made to the LS-513.

20 CFR 702.174 (Certifications) and 175 (Reinstatements)

The burdens assigned these sections were determined by applying response times of 45 minutes (.75 hour) for 702.174 (certifications) and 30 minutes (.5 hour)for 702.175 (reinstatements) against the total responses expected to be received. Based on an average of the number of applications received annually since the last clearance, it is estimated that approximately five (5) new applications will be received each year and two (2) requests for reinstatement will be received. The two sections are related as 702.174 pertains to the certification requirements for builders of small vessels and 702.175 contains the requirements for reinstatement should the certification lapse for some reason. The respective response times are considered reasonable in view of the limited information which is required for both certification and reinstatement. The information required is little more than a confirmation on the part of the applicant that the facility requesting exemption is engaged in the building, repairing or dismantling of exclusively small vessels. The remaining information requested relates to the description of the business, its name and location and whether proper workers' compensation insurance has been secured under a state workers' compensation law. The reinstatement requirements merely require a reaffirmation of the nature of the business and an explanation of the circumstances leading to the termination of the exemption and an affidavit affirming that the termination circumstances no longer exist. All of this information is readily available to the company requesting certification. The burden estimate under Section 702.174 has been estimated to be four (4) hours (.75 hours X 5 applications). The burden for Section 702.175 has been estimated to be one (1) hour (.50 hours X 2 reinstatement requests). Burden for this regulation is not affected by proposed changes made to the LS-513.

20 CFR 702.242 (Settlement applications)

The settlement application must be self-sufficient since it will not only be submitted to District Directors but also to Administrative Law Judges who do not have available all of the information contained in the case file. The district office case file also will not always contain all of the required information. The specific terms of the proposed settlement will vary from case to case as will the reasons for settlement. Burden for this section has been estimated to be approximately 9,498 hours. A response time of 2 hours has been applied against the 4,749 annual responses which are expected to be received each year. The 4,749 response figure was determined by estimating that approximately 20 percent of all lost time injury cases will be settled under the Act's settlement provisions. The 2 hour response time is considered reasonable since the information required is generally available to the parties and is submitted in the form of a summary of events in the development of the case. The 2 hour response time should be viewed as an average response time since some settlement applications will be uncomplicated and therefore will take less time to prepare than some of the more complex applications involving, for example, structured settlements. Settlements of this type involve more than just lump sum payments and can provide for continuing payments in addition to lump sum payments. The information which is required is important and is needed to properly evaluate settlement applications. Total annual burden is estimated to be 9,498 hours (2 hrs x 4,749 settlement applications). Burden for this regulation is not affected by proposed changes to the LS-513.

20 CFR 702.321 (Section 8(f) payments)

Section 8(f) relief is not requested until such time as a claimant's permanent disability is established. Based on actual experience of cases now being submitted for payment from the Special Fund under Section 8(f), there will be 285 such cases each year. A five (5) hour response time is considered reasonable (to collect the information) since the information required is generally available to the parties and has been developed as the case has progressed from the initial injury to the point of maximum medical improvement. Some applications involving complicated medical issues, or where prior medical records are not readily available, may take a substantial amount of time to develop. The 5 hour response time should therefore be viewed as an average since some cases will be more complex than others and will require additional time to prepare than for a routine case in which the pre-existing disability is readily apparent. The annual burden is calculated to be 1,425 hours (5 hours X 285 cases). Burden for this regulation is not affected by proposed changes made to the LS-513.

ESA-100 (LS) (Annual report): This is a recordkeeping requirement pursuant to 20 CFR 702.111 and 201. There are 21,000 record keepers who file two annual reports. It is estimated that it takes one (1) minute (.02 hours) to file an accident report which is considered to be a reasonable amount of time needed for this function. The recordkeeping burden has been estimated to be 840 hours (21,000 x 2 annual reports filings x .02 hours per report). Burden for this requirement is not affected by proposed changes made to the LS-513.

LS-271 (Application for Self-insurance): It is estimated on the basis of past experience and future expectations that there will be approximately 20 respondents for the Form LS-271. Each respondent will submit only one response. The estimated response time of 3 hours for the LS-271 has been determined through actual review of responses submitted on applications for self-insurance authorization submitted to the National Office of the DLHWC.

All applications submitted and approved are maintained in the National Office and are periodically reviewed. Total annual burden is estimated to be 60 hours (3 hours x 20 annual responses). Burden for this form is not affected by proposed changes to the LS-513.

LS-274 (Report of Injury Experience of Insurance Carriers and/or Self-Insured Employer): Based on past experience and future expectations it is estimated that approximately 565 insurance carriers and/or self-insurers will report their outstanding liabilities to OWCP each year. These insurance carriers and/or self-insurers have their outstanding liabilities in computer format which is acceptable to this Office. From a company financial standpoint, loss information on compensation cases would be maintained even if it were not required to be submitted to the OWCP. Without computer capability the LS-274 is manually completed from loss information the company maintains in the normal course of running a business. Reports are filed annually. Burden is currently estimated to be 565 hours (1 hour x 565 reports). Burden for this form is not affected by proposed changes made to the LS-513.

LS-201 (Notice of Employee’s Injury or Death): It is estimated that approximately 3,640 forms will be used each year to report injuries and deaths under the Longshore Act and its extensions. This estimate is based on its use in approximately 20% of the 18,200 lost-time injuries filed each year as determined from a review of case files. It is estimated that approximately 15 minutes (.25 hour) is needed to complete the form. This estimate is considered reasonable in light of the educational backgrounds of those who are expected to complete the forms. For the most part, formal education will be limited since the majority of employment covered by the Act and its extensions is manual labor involving the loading and unloading of vessels. It also has been taken into consideration that in some cases the claimant will complete an additional copy of the form rather than use photocopy facilities since two copies of the form are required. The 15 minute completion time therefore takes all of this into account and should be considered as an average time in which to complete the form. Burden has therefore been estimated to be approximately 910 hours (.25 hours X 3,640 forms). Burden for this form is not affected by proposed changes made to the LS-513.

LS-513 (Report of Payments): Based on actual experience and future expectations, it is estimated that approximately 565 Forms LS-513 will be used each year to report payments made under the Act and its extensions. Each self-insurer and insurance carrier will file only one report per year. A small subset of these entities -- those that self-insure for DBA liabilities or provide DBA insurance coverage -- will now also be required to report their DBA payments by contracting agency on the form; self-insured employers and insurance carriers who do not write DBA coverage will not have to complete this portion of the form. OWCP estimates that out of the 565 respondents, approximately 10 companies will be subject to this new requirement.

For 555 of the respondents, an estimate of 30 minutes is considered a reasonable length of time in which to check company financial records and enter the information on the form. The information requested on the form is readily available from the financial records of the companies since they would be required to maintain the information as a normal business practice even if it were not required by this Office. The estimated time to complete the form is based on the time needed to transfer the needed information from records already in existence onto the form. Burden has been estimated to be approximately 277.5 hours (.50 hours X 555 forms) annually. There is no change in the previously estimated burden for this group of respondents.

For the remaining 10 companies that make DBA payments and will now be required to report those payments by contracting agency, it is acknowledged that these 10 companies may not currently capture the contracting agency in their financial records in a way that can be easily retrieved and reported. Any potential Information Technology System Development is discussed in item 13; however, once this data field can be captured along with the other financial information (if not possible already), it is estimated that the burden for these 10 carriers would be only slightly higher than the other respondents at 1 hour (as opposed to 30 minutes), which allows additional time to enter the contracting agency breakdown on the form. Burden has been estimated to be approximately 10 hours (1 hour X 10 forms) annually. This is an increased burden of 5 hours total for this group of 10 respondents.

For both groups combined, excluding any initial IT costs for the first year which are discussed in item 13, the burden has been estimated to be approximately 287.5 hours (.50 hours X 555 forms plus 1 hour X 10 forms).

Note that previously, DLHWC had estimated a burden of 165 hours based on the assumption that the form may be able to be submitted via a weblink; however, DLHWC has determined that submission via that method is not possible at this time due to budgetary constraints. Therefore, the burden estimate is being increased from the previous estimate of 165 to 287.5 for an additional burden of 122.5 hours.

LS-267 (Claimant’s Statement): This form is used to collect information on death cases only. Formerly, wage information was also collected from totally disabled claimants. The wage information is now collected on Form LS-200 which is a part of this clearance. Completion of the LS-267 now requires only that two boxes be checked and the form be signed and dated. It is estimated that this will take only about two (2) minutes. Based on actual usage of this form by the National office, and the limited number of death cases reported under the Act, it is estimated that approximately 1,125 forms will be completed each year. Burden is estimated to be approximately 37.13 hours (.033 hours X 1,125 forms). Burden for this form is not affected by proposed changes made to the LS-513.

LS-203 (Employee’s Claim for Compensation): It is estimated that approximately 8,190 claim forms will be filed each year with our district offices. This estimate is based on its use in approximately 45% of the 18,200 lost-time injuries that are reported each year. A response time of 15 minutes has been assigned to this form since this form is a basic claim form and the information to complete it is readily available to the claimant since it pertains to the claimant's job and injury. This completion time should be considered as an estimate since some claimants may require more or less time to complete the form. Burden is estimated to be 2,047.50 hours (.25 hours x 8,190 claims). Burden for this form is not affected by proposed changes made to the LS-513.

LS-204 (Attending Physician’s Supplementary Report): The Form LS-204 is a medical report form which requests basic information relating to a claimant's injury. It is estimated based on a usage rate of approximately 3 forms for each of the 18,200 lost-time injuries filed each year that approximately 54,600 forms will be filed each year and that it will take 30 minutes to complete the form. This is considered a reasonable estimate since actual experience with the form has shown that, for the most part, physicians tend to provide brief responses to the questions posed thereby reducing the amount of time needed to complete the form. The examination time of 15 minutes is also considered reasonable in view of the fact that some injuries may be serious, e.g., fractures and other traumatic injuries, which may require more than 15 minutes to complete while others such as minor cuts, sprains and bruises may require less time. The 30 minute period should therefore be viewed as an average time to conduct an examination. Burden is estimated to be 27,300 hours (.5 hour x 54,600 reports). Burden for this form is not affected by proposed changes made to the LS-513.

LS-262 (Claim for Death Benefits): This is a basic claim form which requests information relating to death claims. It is estimated that it will take approximately 15 minutes to complete, since all of the information requested is readily available to the person completing the form. It is estimated based on past experience that approximately 280 death claims will be filed under the Act each year. The number of death claims has remained relatively constant over the years. Burden is estimated to be 70 hours (.25 hours x 280 claims). Burden for this form is not affected by proposed changes made to the LS-513.

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BURDEN SUMMARY HOURS

LS-200 (20 CFR 702.285)........................ 1,904

20 CFR 702.162 (Liens)......................... 5

20 CFR 702.174 (Certifications)................ 4

20 CFR 702.175 (Reinstatements)................ 1

20 CFR 702.242 (Settlement Applications........ 9,498

20 CFR 702.321 (Section 8(f) Payments)......... 1,425

ESA-100 (20 SFR 702.201)....................... 840

LS-271 (Self Insurance Application)............ 60

LS-274 (Injury Report of Insurance Carrier and

Self-Insured Employer)................. 565

LS-201 (Injury or Death Notice)................ 910

LS-513 (Payment Report)........................ 288

LS-267 (Claimant’s Statement).................. 37

LS-203 (Employee Comp. Claim).................. 2,048

LS-204 (Medical Report)........................ 27,300

LS-262 (Claim for Death Benefits).............. 70

 Total Burden Hours............................. 44,955

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The annualized burden cost to the respondents has been estimated to be approximately $744,538 (rounded). This estimate is derived from use of the National Average Weekly Wage (NAWW) as computed by the Bureau of Labor Statistics and which is based on the national average earnings of production or nonsupervisory workers on private nonagriculture payrolls. Section 6(b) of the Act mandates the use of the NAWW in setting the maximum and minimum compensation rates under the Act and in determining the amount of annual adjustments due to permanent total disability and death beneficiaries. Since it is not possible to determine the specific occupation or wages for each person who will provide the information covered by this clearance, e.g., claims adjusters, claims managers, self-insurance administrators, secretaries, claims clerks, longshore workers, shipbuilders, boat builders, physicians, and other office personnel, and wages can vary considerably from person to person depending on duties and length of service, use of a national average weekly wage covering all occupations is reasonable under the circumstances. The current applicable NAWW is $662.59. The computations are therefore as follows: $662.59  40 hrs = $16.56/hr x 44,960 hrs = $744,538 annualized burden cost.

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

The information collections do not require the use of systems or technology for generating, maintaining or disclosing the data above that would not already be used as a customary business practice. Therefore, a mailing cost of $.49 per response ($.46 postage and $.03 envelope charge) is applied as an operation cost. Printing costs for those forms which the industry prints for their own use have been estimated by using a cost of $4.50 per 100 copies for a two-sided form ($2.25 per 100 copies for a one-sided form). All costs and printing estimates have been rounded and those which are less than one dollar have been rounded to a dollar. The costs are as follows:



3

REGULATION/FORM RESPONSES MAILING PRINTING

LS-200 14,000 $6,860 $ 630

20 CFR 702.162 10 5 0

20 CFR 702.174 5 2 0

20 CFR 702.175 2 1 0

20 CFR 702.242 4,749 2,327 0

20 CFR 702.321 285 140 0

ESA-100 Record Only 42,000 0 0

LS-271 20 10 1

LS-274 565 277 25

LS-201 3,640 1,784 164

LS-513 565 277 12

LS-267 1,125 551 51

LS-203 8,190 4,013 369

LS-204 54,600 26,754 2,457

LS-262 280 137 13

TOTALS 130,036 $43,144 $3,722

Total Estimated Costs $46,866



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Additional 1^st year cost only for LS-513 - As noted in item 12, there is a new requirement to report Defense Base Act payments by contracting agency for the LS-513. This affects approximately 10 respondents, who may or may not currently capture this data field in their financial records in a way that can be easily retrieved and reported. If the data field does not currently exist, it will need to be added to the respondents’ Information Technology System. The time to develop and implement one additional data field to capture the contracting agency is estimated to be 20 hours. The burden cost to deploy this one data field if the respondent does not currently capture it in a way that can be easily reported, is estimated to be approximately $770.00 (rounded). This estimate is derived from the Annual Mean Wage for Computer Occupations as computed by the Bureau of Labor Statistics. Since it is not possible to determine the specific occupation or wages for each person who would be involved in an Information Technology change such as this, and wages can vary considerably from person to person depending on duties and length of service, the general Computer Occupations job category was used. The current applicable annual mean wage is $1,538.85 per week. The computation for the first year burden for these 10 respondents is therefore as follows: $1538.85  40 hrs = $38.47/hr x 20 hrs = $769.40. This cost would be for the first year only, since once developed the respondent could obtain the data in the same way as respondents currently do for the other information required by the LS-513.

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

Estimates of annualized cost to the Federal Government for all of the forms and regulations associated with this clearance are as follows:

LS-200, Report of Earnings (20 CFR 702.285): The cost to the government has been estimated to be approximately $78,456 (rounded). This estimate was determined by taking into consideration printing, distribution and analysis cost associated with the issuance and review of Form LS-200. Printing costs were determined by using a cost of $4.50 per 100 copies for a two-sided form for specimen copies distributed to the insurance industry (less than 100 copies annually) which prints their own supplies. In addition, approximately 5,000 forms are sent by the Longshore Division directly to claimants receiving benefits from the Special Fund. The forms are sent via self-mailers at a printing cost of $.21 per form. Distribution costs were determined by applying a postage fee against the number of copies issued ($.46 postage). Analysis and handling costs were determined by applying the hourly rate of a GS-13 claims examiner ($39.21) to the total annual hours required for review. The annual review hours were determined by applying an estimate of .17 hour or 10 minutes for the review and analysis of each form against the 11,200 forms which are expected to be received each year which show earnings. (11,200 forms x .17 hours = 1,904 x 39.21 rate = 74,656 analysis and handling costs. Also 4.50 x 1 = 4.50. 5,000 forms x .21 self-mailers = 1,050. 5,000 forms x .46 postage = 2,300. Therefore, 74,656 + 4.50 + 1,050 + 2,300 = $78,456.)

20 CFR 702.162, 702.174, 702.175, 702.242, 702.321: The cost to the government for the above sections of the regulations were determined by considering the time taken by appropriate Federal personnel at the required grade level to review and take the necessary action in response to receipt of the information collection. For the purpose of the cost estimating requirement, the above sections are being considered together since the GS-13 grade level is appropriate for all the sections. The titles of the individuals responsible for processing the material will vary, e.g., district directors and workers' compensation specialists; however, the grade levels are the same. In addition, in considering the time needed for conducting the analysis and taking appropriate action, a reasonable estimate of .5 hours or 30 minutes was considered valid for each of the sections. The cost to the government was therefore determined by applying the hourly rate of a GS-13 Step 1 Federal worker (currently $39.21 per hour, Salary Table 2012-GS, Rest of US) to the total annual hours required for analysis and processing. The annual review hours were determined by applying the .5 hour estimate assigned for analysis and processing against the 5,051 responses which are expected to be received each year under the above sections. In addition, a 5% overhead adjustment was added to the total cost to account for the internal transfer of the documents received within an office which is considered reasonable. The cost to the government has therefore been estimated to be approximately $103,976.

LS-271, LS-274, LS-201, LS-513, LS-267, LS-203, LS-204 and LS-262: The cost to the government has been estimated to be approximately $70,112. This estimate was determined by taking into consideration printing, distribution and analysis costs associated with the issuance and review of these forms. Distribution costs were determined by applying a postage and envelope charge against the number of copies issued. Longshore forms are generally printed by the industry, therefore only specimen copies are usually distributed. However, small supplies are provided on some occasions. Accordingly, printing costs are minimal as only small supplies are printed. Printing costs are calculated by using a cost of $2.25 per 100 copies for a one-sided form and $4.50 per 100 copies for a two-sided form. Mailing costs were determined by using $.46 for postage and $.03 for an envelope charge. With the exception of the LS-513 all the forms are two-sided forms. Analysis and handling costs were determined by applying the hourly rate of a GS-13 workers' compensation specialist (currently $39.21 per hour) to the total annual hours required for review. The annual review hours are determined by applying the review and analysis estimate of each form against the total number of forms which are received each year (The chart under Item 13 shows the annual responses for each form). The total Federal cost includes the printing and mailing costs and the review and analysis costs. Following is a breakdown by form showing grade level, review and analysis time for each form and individual Federal cost:



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FORM GRADE/RATE ANALYSIS # FORMS FEDERAL COST

LS-271 13/$39.21 3 hours 20 $ 2,353

LS-274 13/$39.21 .5 hour 565 11,079

LS-201 13/$39.21 .02 hour 3,640 2,839

LS-513 13/$39.21 .17 hour 565 3,769

LS-267 13/$39.21 .02 hour 1,125 878

LS-203 13/$39.21 .02 hour 8,190 6,388

LS-204 13/$39.21 .02 hour 54,600 42,588

LS-262 13/$39.21 .02 hour 280 218

Total $70,112



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The Federal cost is not affected by the proposed change to the LS-513.

15. Explain the reasons for any program changes or adjustments.

This section will address the changes in burden. The reason(s) for the changes will be addressed individually for each section affected. However, the burden for all forms has increased by $887 due to an increase in the cost of postage.

LS-513: Burden for this form has been increased by 5 hours from 283 hours to 288 hours. Because approximately 10 respondents will now be required to add the contracting agency, an additional burden has been added as outlined fully in response 12.

Also, as outlined in response 14, it is unclear whether all respondents currently have the capacity to break down expenses by contracting agency since it is unknown whether they currently maintain this data field. If the respondent does not currently have this data field available, an Information Technology System enhancement may be required. The estimated cost is $769.40 and would apply to the first year only.

7

BURDEN CHANGE SUMMARY

Form Change

ESA-100 0

LS-200 0

20 CFR 702.242 0

LS-201 0

LS-513 5

LS-203 0

LS-204 0

20 CFR 702.321 0

LS-274 0

LS-267 0

LS-271 0

LS-262 0

Total Burden Increase 5



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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 will not be published for statistical use.

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.

We are requesting a continuation of the exemption of the provisions of 5 CFR 1320.8(b) which requires that a current expiration date be affixed on all OMB cleared forms for the forms cleared under this OMB clearance (1240-0014).

The usual OMB clearance is for three (3) years. In the Longshore program, users supply and stock most forms. Large insurance carriers and self-insured employers will generally print, or have their own supplies of the forms they use printed. However, small to medium carriers and employers will usually purchase their supplies from large printing companies that stock large quantities of the forms with which to fill small orders. It is difficult to estimate the amount of demand for the forms; therefore, supplies of some forms may stay in stocks for many years before they are all purchased and new supplies are printed. Large carriers and self-insurers also print in large quantities to reduce costs. Since the Longshore program has remained stable for many years, very few, if any, changes are ever required in the forms used. We, therefore, request a continuation of the exemption from the provisions of 5 CFR 1320.8(b) relative to the expiration date requirement for the Longshore forms associated with this clearance.

18. Explain each exception to the certification statement in ROCIS.

There are no exceptions to the certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.