Supporting Statement 1240-0017 2016

Death Gratuity Forms, CA-40, CA-41, and CA-42

1240-0017

June 2016

SUPPORTING STATEMENT

OMB 1240-0017

Death Gratuity Forms

CA-40, CA-41 and CA-42

1. 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 National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of P.L. 110-181 amended the Federal Employees’ Compensation Act (FECA) creating a new section, 5 U.S.C. § 8102a effective upon enactment. This section establishes a FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation. 5 U.S.C.§ 8102a also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001 in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom. 5 U.S.C. § 8102a also allows federal employees to vary the order of precedence of beneficiaries or to name alternate beneficiaries. 20 CFR 10.909 and 10.911 provides that the CA-40, CA-41, and CA-42 as the forms to be used to designate beneficiaries and initiate the payment process for death gratuity benefits. See 5 U.S.C. 8145 and 8149.

https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm

Form CA-40 is an optional form that requests the information necessary from the employee to accomplish this variance and to name alternate beneficiaries only if the employee wishes to do so. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

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 through forms CA-40, CA-41 and CA-42 is used by claims examiners in OWCP to determine a person’s entitlement to any or all of the death gratuity payment provided by 5 U.S.C.§8102a.

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 Division of Federal Employees’ Compensation seeks to allow individuals and entities that deal with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate.

The forms will be available via through the following website in a PDF fillable and printable format in accordance with the GPEA.

These forms are located on DOL/DFEC website:

http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

Due to the low usage of the forms associated with this OMB collection, we believe it sufficient that they be electronically filled only, rather than submitted electronically. They may be downloaded, printed, submitted by mail or electronically uploaded into an imaged case record as described below.

OWCP/DFEC has developed an alternative to mailing of documents. This application, known as The Employee Compensation Operations and Management Portal (ECOMP) is internet based, and allows the users the ability to submit completed forms electronically into their respective case record. This application is available to the claimant, employing agency, and the medical provider. There is no cost to the claimant.

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.

The information requested in these collections is not duplicative of any information available elsewhere in OWCP or in any other Federal executive agency. The beneficiary classes under this benefit program are different than under any other FECA benefit and also cover NAFI employees, which have previously never been covered under FECA. The respondents are the only source of all the required information.

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

This information collection has been streamlined to obtain the necessary information while imposing the minimum burden on the respondent. This information collection does not have a significant economic 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.

If this information were not collected, OWCP would be unable to administer and provide the death gratuity to the appropriate beneficiaries, as required by the statute.

7. Explain any special circumstance.

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. Specifically address comments received on cost and hour burden.

The last Federal Register Notice inviting comment was published on April 13, 2016 (81FR21905). Comments were not received.

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

The decision to provide a payment to a respondent is a decision on entitlement to death gratuity benefits under the FECA by OWCP.

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

The information collected by these requests is maintained in FECA claim files, which are fully protected under the Privacy Act. Records pertaining to compensation cases are covered under the Privacy Act. The Privacy Act Notice is provided on each of the forms. All forms used to initiate a compensation claim contain a statement advising the claimant of the revisions of the Privacy Act. The applicable Privacy Act system of records is called DOL/GOVT-1.

See web site: http://www.dol.gov/sol/privacy/dol-govt-1.htm.

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.

No questions regarding sexual behavior, religious beliefs, etc. are asked by the CA-40, CA-41 or CA- 42.

12. Provide estimates of the hour burden of the collection of information.

The following chart shows the projected burden hours for these forms. DFEC cannot accurately determine the projected burdens for the CA-40 as this number is always approximate and based on the fact that there are fewer deployments. Additionally, the CA-40 (which is initially maintained at the employing agency) is an optional form. This form requires completion only if the claimant wants to change the usual distribution of benefits. The employing agency submits this form, along with the CA-41 and the CA-42 to DFEC, upon death in very specific circumstances. Therefore, completion of this form is just an estimate.

The figures for the CA-41 and CA-42 are based on actual numbers from 2013 through 2015. The Cleveland district office, which is responsible for processing these types of claims, has processed only 6 Death Gratuity claims over the last 3 years.

The estimates below represent the average time it takes one respondent to complete one response.

Form	Time to Complete	Frequency of Response	Number of Respondents	Number of Responses	Hours Burden
CA-40 Individual Respondent	15 min.	1	250	250	63
CA-41 Individual Respondent	15 min.	1	6	6	2
CA-42 Agency Respondent	20 min.	1	6	6	2
Totals			262	262	67

The combined burden hours have been calculated to be 67. Because the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage for production or non-supervisory workers on private nonagricultural payrolls as computed by BLS, or $25.24 per hour.  $25.24 X 67 = $1,691. 08 or $1691.00 rounded down.

http://www.bls.gov/opub/ee/2015/ces/summarytable_201512.pdf

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

Because the information requested from individual respondents will be readily known, there are no capital/start-up costs. The CA-40 is only required if the employee chooses to alter the order of precedence or provide an alternate beneficiary if the employee does not want it to follow the statute.  As a result, a large number of people being deployed would probably have no need to fill out the CA-40. This form, as well as the CA-42, would be maintained by the federal employing agency. Therefore, the only actual cost the respondents must bear is the cost of mailing the Form CA-41.

The mailing costs are calculated as follows:

Total claimant costs Forms CA-41

[$0.49 (postage) + $0.03 (envelopes)] x 6 (forms) =$3.12(or $3. 00 rounded down).

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

Review Costs: The average hourly wage for the reviewer is that of a GS-12/10, $45.98 per hour

See website, https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2016/CLE_h.pdf

Form	Time to Review	Total Responses	Costs
CA-40	30 minutes	6	$138.00
CA-41	30 minutes	6	$138.00
CA-42	30 minutes	6	$138.00
Totals			$414.00

Federal Cost Estimates:

Printing Cost: There will be no printing cost since the CA-40, CA-41 and CA-42 will only be stored in OWCP’s ADP systems in a word processing program

Mailing and Envelope Cost: The CA-41 is the only form that requires mailing and postage. $0.49 (postage) + $0.03 (envelope) X 6 = $3.12 or $3.00, rounded down.

Total Federal Cost: $414.00 +$3.00 = $417.00 (review costs + postage)

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

The number of claims received for death gratuity varies from year to year. Only 6 death gratuity claims were received between 2013 and 2015. As these operations have winded down since their inception, the number of claims have decreased. Furthermore, as the CA-40 is an optional form, used only when an employee wishes to vary the order or preference or designate an alternate beneficiary for payment, not all employees choose to fill out this form prior to deployment or may choose to rely on a designation from an earlier deployment, so the number of people filling out this form varies greatly year to year. 

Therefore, the previous approved number of annual respondents 272 is now 262, which represents a decrease in 10 respondents. The previously approved number for burden hours was 70; the requested number now is 67, which is a decrease of 3. Likewise, the costs burden for maintenance and reporting costs (postage and envelope) decreased from $5.00 to $3.00, which is a decrease of $2.00.

A summary of revisions:

For all 3 forms, CA-40, 41, and 42:

1. Placed the following Accommodation language on the bottom of the form.

“If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP. See Instructions for additional details.”

2. Added the following language in the Instructions regarding Accommodations. Similar statement is currently found on page with Privacy Act and Public Burden page, which this now takes the place of.

“If you have a disability, Federal law gives you the right to receive help from the OWCP/DFEC in the form of communication assistance, accommodation(s) and modification(s) to aid you in the claims process. For example, we will provide you with the copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or your OWCP claims examiner to ask about this assistance. “

For CA-41:

1. Revised the Survivor Declaration Statement on page 3.

Current:

“I hereby certify that each and every statement made above is true and accurate to the best of my knowledge. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by 5 U.S.C. 8102 or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both”.

Revision:

“I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by 5 U.S. C. 8102, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits. “

2. Added Direct Deposit Information to the form on page 3.

24. Name of Financial Institution for Depositing Benefits: Checking Savings

25. Account Number 26. Routing or Transit Number

3. Add to Instructions the following statement in regards to Direct Deposit Information

Items 24 through 26.

“The Department of the Treasury requires all Federal payments be made by electronic funds transfer (EFT), also called Direct Deposit. If you have not previously signed up to receive compensation with EFT, or desire to change your current account information, please submit SF-1199A, Direct Deposit Sign Up. If you do not have a bank account, you may be required to receive your payment through Direct Express Debit MasterCard. To request information on the Direct Express Debit MasterCard, go to www.usdirectexpress.com or call 1-800-333-1795. If directed to enroll in the Program, you may contact the Department of the Treasury at 1-888-224-2950 to address any questions or concerns you may have, as well as apply for a waiver from the process. NOTE: payments to residents of foreign countries are exempt from the Treasury requirements.”

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.

Data collected by the CA-40, CA-41 and CA-42 will not be published.

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.

No exception to the display of the expiration date is sought.

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

This request is in compliance with 5 CFR 1320.9.

2. Collections of Information Employing Statistical Methods:

Statistical methods are not used in these collections of information.