Request for Employment Information

Forms and Documents

Document Name	Status
Form ca-1027 Request for Employment Information Form and Instruction	Modified
RUS_h-opm wage chart 2015.pdf Supplementary Document	2015-07-20
OMB 1240-0047 table b8 National Average Weekly Wage for Production or Nonsupervisory workers on private nonagricultural payrolls-2015.docx Supplementary Document	2015-07-20
Section 8106.doc Supplementary Document	2015-07-20
Supporting Statement 1240-0047 (CA-1027).docx Supporting Statement A	2015-10-22

IC Document Collections

IC ID	Document Title	Status
13773	Request for Employment Information Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0047	ICR Reference No: 201507-1240-003
Status: Historical Active	Previous ICR Reference No: 201209-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Employment Information
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: 05/06/2016
	Date Received in OIRA: 01/29/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved	05/31/2016
Responses	154	0	431
Time Burden (Hours)	39	0	108
Cost Burden (Dollars)	74	0	207

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Abstract: This information collection is used to collect information about a claimant's employment. It is necessary to determine continued eligibility for compensation payments under FECA.

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Authorizing Statute(s): US Code: 5 USC 8106 Name of Law: Federal Employees' Compensation 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 51322	08/24/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 8252	02/18/2016
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
Request for Employment Information	ca-1027	Request for Employer Information

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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	154	431	0	0	-277	0
Annual Time Burden (Hours)	39	108	0	0	-69	0
Annual Cost Burden (Dollars)	74	207	0	0	-133	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: There is a reduction in the number of respondents from the previous submission of 431 to 154, a decrease in 277. Accordingly, the previous cost burden amount of $207 to is adjusted to $74, a decrease of $133. The previous burden hour cost of 108 is adjusted to 39, a difference of 69. The adjustments are resultant from a decrease in the number of claims for wage loss filed by former federal employees in which earnings information is sought from a private employer.

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Annual Cost to Federal Government: $1,967

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: 01/29/2016

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