TSA Claims Management Branch Program

Forms and Documents

Document Name	Status
Form CMB 6-1-10 TSA Claims Management Branch Program Form	Modified
DHSTSA 006 Correspondence and Matters Tracking System 75 FR 18863 4132010.pdf Supplementary Document	2015-07-08
DHSTSA 009 General Legal Records 68 FR 49496 8182003.pdf Supplementary Document	2015-07-08
28 CFR 14-2.pdf Supplementary Document	2015-07-08
1652-0039 TSA CMBP 30DN 80 FR 32973 (June10_2015).pdf Supplementary Document	2015-06-12
1652-0039 TSA CMBP 60DN_80 FR 17470(4_1_15).pdf Supplementary Document	2015-06-12
Sample Letters.pdf Supplementary Document	2009-11-10
CMS Screen Shots.doc Supplementary Document	2009-08-24
1652-0039 TSA CMBP SS_782015.docx Supporting Statement A	2015-07-08
SF95.pdf Supplementary Document	2009-08-21
Federal Tort Claims Act.pdf Supplementary Document	2009-08-21

IC Document Collections

IC ID	Document Title	Status
43964	TSA Claims Management Branch Program Form	Modified

ICR Details

OMB Control No: 1652-0039	ICR Reference No: 201506-1652-002
Status: Historical Active	Previous ICR Reference No: 201111-1652-006
Agency/Subagency: DHS/TSA	Agency Tracking No: 1652-0039
Title: TSA Claims Management Branch Program
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/04/2016
	Date Received in OIRA: 07/16/2015
Terms of Clearance: The agency amended the forms attached to this ICR.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2019	36 Months From Approved	12/31/2015
Responses	10,000	0	12,000
Time Burden (Hours)	5,000	0	6,000
Cost Burden (Dollars)	14,800	0	17,760

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Abstract: TSA Claims Management Branch (CMB) requests to continue collection of certain information to investigate tort claims filed against TSA for property damage, property loss, personal injury, or death. TSA needs to collect certain information from claimants, in addition to that collected on the Standard Form 95, to investigate claims properly. TSA is seeking continued approval for two forms associated with this process.

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Authorizing Statute(s): US Code: 28 USC 1346(b), 1402(b), 2401(b), Name of Law: Federal Tort Claims 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:
	80 FR 17470	04/01/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 32973	06/10/2015
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
TSA Claims Management Branch Program	95-109, CMB 6-1-10	Claim Settlement Letter ,   Claim for Damage Injury or Death

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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	10,000	12,000	0	-2,000	0	0
Annual Time Burden (Hours)	5,000	6,000	0	-1,000	0	0
Annual Cost Burden (Dollars)	14,800	17,760	0	-2,960	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden estimates have decreased due to the steady decline of claims received over the past three years.

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Annual Cost to Federal Government: $194,688

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: 07/16/2015

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