Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form	Modified	Available
Privacy Act Systems - DOL-GOVT-1_mht.htm	Supplementary Document	Uploaded 2017-01-18	Available
OPM Salary Table.pdf	Supplementary Document	Uploaded 2017-01-18	Available
Employment Earnings Table.docx	Supplementary Document	Uploaded 2017-01-18	Available
5 USC Sections 8105, 8106, 8110, 8132 and 8148.doc	Supplementary Document	Uploaded 2017-01-18	Available
20 cfr 10.528.doc	Supplementary Document	Uploaded 2017-01-18	Available
June 24, 2005 Final FECA Feasability Report - (CA-1032).pdf	Supplementary Document	Uploaded 2017-01-18	Available
Supporting Statement 1240-0016 2017.doc	Supporting Statement A	Uploaded 2017-02-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13834	Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form	Modified

ICR Details

OMB Control No: 1240-0016	ICR Reference No: 201701-1240-003
Status: Historical Active	Previous ICR Reference No: 201310-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
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: 08/16/2017
	Date Received in OIRA: 05/31/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved	08/31/2017
Responses	45,161	0	44,800
Time Burden (Hours)	15,054	0	14,933
Cost Burden (Dollars)	5,166	0	23,296

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Abstract: Form CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

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Authorizing Statute(s): US Code: 5 USC 8101-8193 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:
	82 FR 11946	02/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23608	05/23/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement

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ICR Summary of Burden

table that charts list 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	45,161	44,800	0	0	361	0
Annual Time Burden (Hours)	15,054	14,933	0	0	121	0
Annual Cost Burden (Dollars)	5,166	23,296	0	0	-18,130	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 previous approved number of annual respondents, 44,800 is now 45,161, which represents an increase of 361. The previously approved number for burden hours was 14,933 and the requested number now is 15,054, an increase of 121 hours. The annual cost burden is now estimated at $5,166, which is a decrease from the previously approved burden estimate of $23,296, which is an adjustment of $18,130.

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Annual Cost to Federal Government: $437,272

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: 05/31/2017

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