Benefit Appeals Report

Forms and Documents

Document Name	Status
Form ETA 5130 Benefit Appeals Report Form and Instruction	Modified
1205-0172 Supporting Statement_FINAL 12.12.16.doc Supporting Statement A	2016-12-12

IC Document Collections

IC ID	Document Title	Status
13008	Benefit Appeals Report Form and Instruction	Modified

ICR Details

OMB Control No: 1205-0172	ICR Reference No: 201611-1205-004
Status: Historical Active	Previous ICR Reference No: 201305-1205-001
Agency/Subagency: DOL/ETA	Agency Tracking No: UPI 012-05-01-05-01-2035-00
Title: Benefit Appeals Report
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: 05/18/2017
	Date Received in OIRA: 02/06/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved	05/31/2017
Responses	1,272	0	1,908
Time Burden (Hours)	1,272	0	1,908
Cost Burden (Dollars)	0	0	0

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Abstract: The ETA 5130, Benefit Appeals Report, contains information on the number of appeals and the resultant decisions classified by program, appeal level, cases filed and disposed of (workload flow), and decisions by level, appellant and issue. The data on this form are used to monitor the benefit appeals process in the state workforce agencies (SWAs). Data are also used for budgeting and workload data.

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Authorizing Statute(s): US Code: 42 USC 503(a)(6) Name of Law: Social Security 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 51941	08/05/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 9399	02/06/2017
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
Benefit Appeals Report	ETA 5130	Benefit Appeals Report

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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	1,272	1,908	0	-636	0	0
Annual Time Burden (Hours)	1,272	1,908	0	-636	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: This ICR seeks no approval for discretionary actions affecting respondent burden. However, adjustments were made to reflect the expiration of Federal Emergency Unemployment Compensation Program, which occurred on January 1, 2014. DOL has refined the burden estimate entries for this collection, to make the relationship between reginfo.gov database information more consistent with the burden reported to respondents. As shown in item 12, each month States submit a separate ETA 5130 for each of the two programs and each form takes 1 hour to complete. The form provides that burden estimate. The database, however, reflected a single monthly response taking two hours.

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Annual Cost to Federal Government: $26,367

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: 02/06/2017

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