Claim for Compensation by a Dependent Information Reports

Forms and Documents

Document Name	Status
Form CA-1031 Claim for Compensation by a Dependent Information Reports Form	Modified
BLS Average hourly and weekly earnings, production and nonsupervisory employees on private nonfarm payrolls omb1240-0013mjs 2016.pdf Supplementary Document	2016-02-10
20 cfr 10.7 etc.docx Supplementary Document	2016-02-10
opm salary table 1240-0013 2016.pdf Supplementary Document	2016-02-10
5 usc 8110 augmented compensation for dependents.docx Supplementary Document	2016-02-10
Privacy Act System of Records-DFEC for omb 1240-0013.doc Supplementary Document	2016-02-10
5 usc 8110 augmented compensation for dependents.docx Supplementary Document	2016-02-10
SSA 1240-0013 supporting statement 2016.doc Supporting Statement A	2016-08-18

IC Document Collections

IC ID	Document Title	Status
13841	Claim for Compensation by a Dependent Information Reports Form	Modified

ICR Details

OMB Control No: 1240-0013	ICR Reference No: 201602-1240-003
Status: Historical Active	Previous ICR Reference No: 201302-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
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: 12/12/2016
	Date Received in OIRA: 08/24/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	12/31/2016
Responses	1,675	0	2,920
Time Burden (Hours)	964	0	1,571
Cost Burden (Dollars)	871	0	1,431

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Abstract: The forms included in this package are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation from federal employees/ their dependents/ survivors, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency.

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Authorizing Statute(s): US Code: 5 USC 8124 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8110 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8149 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:
	81 FR 12129	03/08/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 57937	08/24/2016
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
Claim for Compensation by a Dependent Information Reports	CA-5, CA-1031, CA-1074, CA-5b	Claimant Support of Dependent ,   Request for Clarification of CA-5b ,   Claim for Compensation by Widow, Widower, and/or Children ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren

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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	1,675	2,920	0	0	-1,245	0
Annual Time Burden (Hours)	964	1,571	0	0	-607	0
Annual Cost Burden (Dollars)	871	1,431	0	0	-560	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: The estimated number of annual respondents (1,675) is a decrease of 1,245 from the previous request of 2,920. The estimate in burden hours (964) is a decrease of (607) from the previously approved 1,571. Additionally, the estimated cost burden of $871 is $560 less than the previously requested of $1,431. Much of the decrease associated with burden costs and hours is attributed to a significant reduction of respondents in the use of the CA-1074, Student Dependency, and CompDueDeath Letters To determine the estimated number of respondents, DFEC used a computer generated listing to provide numbers based on documents that are imaged in the claimant’s case file based on category/subject/author date. However, initial numbers, particularly for the CompDeathDue for example, were skewed. Upon closer review of the imaged record, it was found that the category/subject of this letter varied in many instances, which resulted in DFEC to actually review the case records to determine a more accurate estimate for this letter. Any document that is imaged into a claimant’s case file is viewed using a category/subject/author date, etc.

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Annual Cost to Federal Government: $16,388

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: 08/24/2016

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