OMB - Supporting Statement for 1240-0026 (LS-266)

SUPPORTING STATEMENT

Application for Continuation of Death Benefit for Student

(LS-266)

OMB No. 1240-0026

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. This Act was amended on October 27, 1972, to provide for continuation of death benefits for a child or certain other surviving dependents after the age of 18 years (to age 23) if the dependent qualifies as a student as defined in section 2 (18) of the Act. The benefit would also be terminated if the dependent completes four years of education beyond high school. Form LS-266 is to be submitted by the parent or guardian for whom continuation of benefits is sought. The statements contained on the form must be verified by an official of the education institution. The information is used by the DOL to determine whether a continuation of the benefits is justified.

Legal authority for this information collection is found at

33 USC 902(18) and 33 USC 939(a). Regulatory authority is found at 20 CFR 702.121.

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 from the LS-266 is used by the OWCP to assure that a claimant receives all of the benefits under the Act to which he/she may be entitled to receive. If the information were not collected, there would be no way to determine the proper status of a student and therefore his/her continued entitlement to benefits.

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), this information collection is not practicable for electronic submission. The extremely small number of respondents, the need for two separate electronic signatures from respondents at different locations, and the even smaller number of respondents who would have access to an electronic option given the need for electronic signatures, make electronic submission impracticable and not cost effective for this population of respondents. While the document is not available for electronic submission it is available on our website for completion online and printing prior to the parties affixing their signatures and submission to the appropriate district office. The website is: http://www.dol.gov/owcp/dlhwc/ls-266.pdf.

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.

All forms in the Longshore program have been carefully reviewed to eliminate all requests for duplicate information.

5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.

To the extent that colleges and universities are considered

as small businesses, burden has been kept to a minimum in that little more than a certification is needed from the college or university to verify the information provided on the form by the parent or guardian. 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.

The information is requested only on occasion when needed and therefore cannot be collected less frequently.

7. Explain any special circumstances.

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 form is primarily completed by parents and guardians of dependents who are also students. A very small number of forms are completed each year. The form also requests only basic claims information needed to verify entitlement to benefits. Given the nature of the claims examining process, the OWCP has daily contact with claimants and industry representatives that submit forms under the Act. The adequacy of the data submitted is discussed as well as the format. Pursuant to these discussions, forms are periodically revised.

A Federal Register Notice inviting public comment was published on November 15, 2013 [78FR68867]. No comments were received.

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

No payment or gift is provided to respondents.

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

The Agency officer provided no confidentiality assurance in association with this information collection.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, 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.

Based on information from existing files and new death claim submissions, it is estimated that approximately 20 Forms LS-266 will be used each year to apply for the continuation of a death benefit for a student. It is estimated that approximately 30 minutes or .5 hours will be needed to obtain the information required by the form and to complete it. This estimate includes the time needed by the parent or guardian and the official of the institution in which the student is enrolled. This estimate is considered reasonable in light of the type of information requested and the fact that the information should be readily available to those persons completing the forms. This estimate also takes into consideration that the parent or guardian may complete an additional copy of the form rather than use a photocopy of the original. Total annual burden for 20 forms at 30 minutes each is 10 hours (20 X .5 hours = 10.00 hours).

The annualized burden cost to the respondents has been estimated to be approximately $168.30. 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, 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 appears reasonable under the circumstances. The current applicable NAWW is $673.34.

Burden Summary

Respondents: 20

Responses: 20

Hours: 10

Monetized: $168.30

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

This information collection does not require the use of systems or technology for generating, maintaining or disclosing the data above that which would already be kept as a customary business practice. A mailing cost of $.46 per response for postage and $.03 for envelopes is applied as an operation cost, with a total of $9.80 for the 20 responses. (.49 mailing cost x 20 responses = $9.80).

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

The cost to the government has been estimated to be approximately $73. This estimate was determined by taking into consideration printing, distribution and analysis costs associated with the issuance and review of Form LS-266. The cost to print a two-sided form is $4.50 per 100 copies. Distribution costs were determined by applying a postage and envelope charge ($.46 and $.03 respectively) against the number of copies issued. Analysis and handling costs were determined by applying the hourly rate of a GS-12, step 4 claims examiner ($36.27/hr) to the total annual hours required for review. The annual review hours were determined by applying an estimate of .08 hour or 5 minutes for the review and analysis of each form against the 20 forms which are received each year (.08 x 20 = 1.60 hours). The Salary Table 2013-RUS was used for the claims examiner. The computations are as follows:

Printing $4.50 (100 copies at $4.50/100 copies)

Distribution 9.80 (20 forms x $.49)

Analysis 58.03 (1.60 hrs x $36.27/hr)

Total $72.63

15. Explain the reasons for any program changes or adjustments

There has been a decrease in burden from 22 hours to 10 hours due to a decrease in the number of forms received. The decrease in the operation and maintenance cost from $20.68 to $9.80 is also due to a decrease in the number of forms received.

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.

The expiration date will be displayed.

18. Explain each exception to the certification statement identified 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.