OMB SUPPORTING STATEMENT
RI 30-10 Disabled Dependent Questionnaire
Justification
Title 5, U. S. Code, Sections 8341(a)(4)(B) and 8441(4)(B) provide survivor benefits for unmarried, dependent children, regardless of age, who are incapable of self-support because of mental or physical disability incurred before age 18. Section 8901(5)(B), which defines the family members who are eligible for health benefits coverage, includes any unmarried, dependent children, regardless of age, who are incapable of self-support because of mental or physical disability which existed before age 22. RI 30-10 is designed to collect information about the disabled child’s ability to earn a living and to obtain medical facts about the disability.
The information collected is used by the Office of Personnel Management (OPM) to determine whether to pay benefits and include the individual as a family member for health benefits coverage. The person applying is asked about the disabled person’s wage-earning capability, and the attending physician is asked to describe the disability and give other information about the disability and its effect on the person’s ability to make a living. If the information is not collected, OPM cannot determine eligibility or pay benefits, as required by law. The Privacy Act Statement (PAS) has been revised due to a general systematic review by our Chief Privacy Officer for all OPM PAS.
The information collected is detailed and can only be obtained from the respondents. New methods of information technology would do little to reduce the burden on the respondents; they must sign the questionnaire and take it to their physician. However, this form is available on our website in a pdf fillable format and meets our GPEA requirements.
The questionnaires are filed individually because there is no other way to obtain this information. Duplication is minimized.
This information collection request has no impact on small businesses and organizations.
This information collection is performed as needed to pay benefits or enroll eligible persons. Less frequent collection would delay the payment of survivor annuities or health benefits enrollment provided by law.
There are no special circumstances involved in the collection of this information.
A notice of proposed information collection was published in the Federal Register on May 5, 2017, giving persons outside the agency an opportunity to comment on the form. No comments were received.
No gifts or payments of any kind have been provided to any individuals who are connected to this collection.
This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses for disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008).
The information collection does not include questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. However, RI 30-10 does collect information regarding the disabled child’s medical condition. The information is needed so that OPM can determine whether the child is disabled within the meaning of the law. The respondent is aware that OPM needs the medical documentation and assists in the transaction by taking the RI 30-10 to the child’s physician to obtain the required medical documentation.
12.
Approximately 2,500 Disabled Dependent Questionnaires will be
processed each year.
Form RI 30-10 requires approximately
60 minutes for completing. The annual burden of
2,500
hours is estimated.
Form Name |
Form Number |
No. of Respondents |
No. of Responses per Respondent |
Average Burden per Response (in hours) |
Total Annual Burden (in hours) |
Average Hourly Wage Rate |
Total Annual Respondent Cost |
Disabled Dependent Questionnaire |
RI 30-10 |
2,500 |
1 |
1 hour |
2,500 |
$0 |
$0 |
We estimate that respondents pay $100 to $150 to obtain needed medical records and physician’s statements. They do not necessarily have to get a special medical evaluation to fulfill the OPM requirements.
13. There is no change in the respondent burden.
14. The annualized cost to the Federal government is $7,725. This
cost was determined by
employee salary hours devoted to
the program, forms cost, and overhead.
15. N/A
16. No information collected from the form will be published.
17.
The Retirement Services program office is the lone processor of the
data collected on
these ICRs from approximately 2.8
million customers. The substance of each information
collection does not substantively change at each OMB renewal cycle,
but according to
changes in law and regulation. These
forms are printed and published (internet, intranet
and
on-board systems) through various agencies for distribution to and
implementation
by Government customers. Pursuant to title
5 CFR 1320.8(b)(1), it would not be
appropriate to
display the OMB clearance expiration date where the form will not be
revised for the foreseeable future (e.g., because it is used to
collect applicant, annuitant,
or beneficiary information
required by long-standing statutory provisions), where use of
the paper form is prevalent, and where, accordingly, it will be
expensive and burdensome
to restock the paper forms
inventory with a new version. Last year, under current practice,
Retirement Services printed approximately 2 million documents
subject to OMB clearance
at a cost of approximately
$85,000. Our costs would rise substantially if additional
revision cycles are added. Lastly, by adding the OMB clearance
expiration date to the
existing format, the end users of
OPM’s ICRs may erroneously assume that the expiration
date affects the validity of the information collection when it is
the OMB clearance
expiration date and not reflective of the
substance. This may lead to additional submissions
by
customers, possible litigation and increasing pressures on our
Operations workloads.
Therefore, we seek approval to not
display the OMB clearance expiration date on the
forms and
to communicate version changes to the public via the revision date.
18. There are no exceptions to the certification statement.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | OMB SUPPORTING STATEMENT |
| Author | MEMOORE |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |