Notice of Recurrence
1240-0009
August 2017
SUPPORTING STATEMENT
Notice of Recurrence
OMB NO.1240-0009
A. 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 Office of Workers’ Compensation Programs administers the Federal Employees’ Compensation Act, (5 USC 8101, et seq.), which provides for continuation of pay or compensation for work related injuries or disease that result from Federal Employment. Regulation 20 CFR 10.104 designates form CA-2a as the form to be used to request information from claimants with previously accepted injuries who claim a recurrence of disability, and from their employer, if applicable. The form requests information relating to the specific circumstances leading up to the recurrence as well as information about their employment and earnings.
References:
https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm
In the vast majority of cases, recurrences of disability are claimed while a claimant continues to be employed by the Federal Government. In those cases, the form is completed by a Federal employee and their federally employed supervisor, and thus does not affect the public. The form is required from the public when the claimant is a former employee and part of the general public when the recurrence occurs. In this case, there is no official supervisor. However, since the same information is required of both former and current employees, all the claimant information must still be provided by the claimant. The last Federal employer of a former employee is asked to provide information about the claimant when they returned to work after the original injury or when last employed as a Federal employee. During CY14 - CY16, the following number of recurrence claims were filed and processed by district offices: CY2014 (6,601); CY2015 (5,576), and CY2016 (5,132), for average of 5,770. It is estimated that 5% of all claims (5,162 x .05) = 289 are filed by claimants after leaving Federal employment. Therefore, this request for clearance pertains to about 5% of the overall use of this form.
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 provided is used by OWCP claims examiners to determine whether a claimant has suffered a recurrence for medical treatment and or disability related to an accepted injury and, if so, the appropriate benefits payable.
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 Form CA-2a is available on-line in a PDF fillable and printable format at http://www.dol.gov/owcp/regs/compliance/ca-2.pdf.
This form has not been made available for electronic submission for the following reasons.
1) The majority of respondents to the form are Federal Employees (5,770 annually) who are responding in their employment capacity; therefore, they not considered to be responding to a PRA covered information collection imposed on members of the General Public (see 5 CFR 1320.3(c) (4)), Only 5% (289 annually) of the respondents are no longer on the Agency Rolls and are therefore members of the General Public. Benefits of an electronic filing option would not justify the cost.
2) The form requires multiple signatures. If any one entity in the approval chain does not have access to electronic filing or does not own a digital signature, the submission process for the form will terminate prematurely. This would then require OWCP to reprocess the form in a paper format for proper completion, which is duplicative and defeats the purpose of the GPEA.
However, to improve upon the capabilities for the public to submit DFEC documents, OWCP 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 these forms electronically into their respective case record. This application is available to the claimant, employing agency, and medical provider, as appropriate. There is no cost involved to the general public.
References:
https://www.gpo.gov/fdsys/pkg/CFR-2011-title5-vol3/pdf/CFR-2011-title5-vol3-sec1320-3.pdf
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 on the Form CA-2a is not duplicative of any information available elsewhere. The claimant is the only source of this information.
While DFEC maintains a database for claims and could easily identify a claim based on their name, date of birth and/or social security number (1, 2, 4 of the CA-2a), in some instances a claimant may have multiple claims. Hence, the claimant would need to identify the claim in which they believe is a recurrence (item 3 of the CA-2a). Additionally, identifying the claim is requested as in some instances claims have been retired, no longer active, or since destroyed.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
This information collection does not have an effect on small businesses.
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.
This form is only required one time for each recurrence claimed by an individual. All of the evidence requested by the form is necessary for OWCP to determine what benefits are payable for a claimed recurrence. Without the requested information an eligible beneficiary could be denied benefits, or benefits could be authorized at an incorrect rate, resulting in an underpayment or overpayment of compensation.
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.
A Federal Register Notice inviting comment was published on May 23, 2017, [82FR23613]. Public comments were not received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations or agency policy.
The information colleted by this form in maintained in FECA claims forms, which are fully protected under the Privacy Act, and Form CA-2a contains a Privacy Act statement detailing the uses of the information a respondent provides and when information might be disclosed to others. The applicable Privacy Act system of records is DOL/GOVT-1 (Office of Workers’ Compensation Programs, Federal Employees’ Compensation Act File).
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.
Requesting the claimant to supply date of birth and social security information (items 2 and 4 of the CA-2a) would be considered sensitive but essential in determining entitlement to benefits under the Act.
The medical information requested in items 19 through 22 would also be considered sensitive. The notice of recurrence, completed by a claimant, authorizes a physician, hospital, institution, corporation, or any government agency, to furnish information to OWCP in the processing of the claim to determine entitlement.
12. Indicate the number of respondents, frequency of response, annual hour burden and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents are desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information.
The CA-2a requires the respondent to provide the information on events leading to a recurrence of disability, medical condition, employment and earnings. Since the claimant should have the requested information readily available, it would simply be a matter of filling out the form. Past experience with this form indicates that it will take approximately 30 minutes for the completion of the form, including reading instructions and providing all requested information.
1/2 hour x 289 = 144.5 or 145 hours rounded up
The information does not require looking up any records, and is readily known to the respondent. This form is used by an individual to voluntarily initiate a claim for monetary benefits. Because the wage category of most of the respondents is not known, we have estimated the cost of the burden hours using the National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls ($21.80 per hour) as computed by BLS,.
$21.80 X 145 hrs. = $3,161.00----respondent burden hour cost.
Reference: https://www.bls.gov/web/empsit/ceseeb8a.htm
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
There are no startup costs for this information collection. Operation and maintenance costs consist solely of mailing costs.
Operating and maintenance costs consist of the price of postage and envelope to return the form.
$.49¢ postage + $.03¢ for the envelope x 289 (forms) =$150.28 or $150.00, rounded down.
14. Provide estimates of annualized cost to the Federal government.
Review Costs:
Time to review each form - 1/2 = .50 of an hour
Hourly wage of reviewer - $35.73 (GS -12/2 RUS)
Reference: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/RUS_h.pdf
Their review costs is calculated as $35.73 X 30 min x 289/60 = $5,162.985 or $5,163.00 rounded up.
Form |
Time to Review |
Total Responses |
Costs |
CA-2a |
30 minutes |
289 |
$5,163.00 |
Federal Cost Estimates:
Printing Cost: Due to the small number of respondents that OWCP contemplates will submit a Form CA-2a; there are no plans to print the form in bulk for distribution.
Mailing and Envelope Cost:
$.49¢ postage + $.03¢ for the envelope x 289 (forms) = $150.28 or $150.00, rounded down.
Total Federal Cost: Processing ($5,163.00) + Mailing costs ($150.00) = $5,313.00
15. Explain the reasons for any program changes or adjustments reported in ROCIS.
The adjustment for this submission is due to an increase in the number of claims since the last approval. Over the last three calendar (CY2014-2016) an average of 5,770 recurrences were submitted, an increase of 608 claims per year (5,162 was the average figure in the previous ICR submission in 2014). In applying the 5% rule described in the discussion in section A.1 above towards the number of claims being submitted by claimants who have left federal employment, the number of claims submitted by this group during this period is 289 (.5% x 5,770). This figure represents an increase of 31 claims since the last OMB submission, 258 (5% of 5,162 ) The requested annual cost burden in dollars is $150 (.52 x 289), which is an increase of $16.00 from the previous submission of $134 (.52 x 258).
Summary of changes to the form:
A revised accommodation statement has been added to page 5 of the form, but this change does not increase the burden for filling out the form. The revised text was made as a response to an EEOC comments response in 2015.
Changes are as follow:
Old: Accommodation Statement
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.
New: REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES
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/or modification(s) to aid you in the FECA claims process. For example, we will provide you with 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 your OWCP claims examiner to ask about this assistance.
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.
The information collected with this form 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 display of the expiration date is sought.
18. Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to certification.
B. Collection of Information Employing Statistical Methods
This information collection does not employ statistical methods.
| File Type | application/msword |
| File Title | Supporting Statement |
| Author | US Department of Labor |
| Last Modified By | SYSTEM |
| File Modified | 2017-08-31 |
| File Created | 2017-08-31 |