Rehabilitation Maintenance Certificate

Forms and Documents

Document Name	Status
Form OWCP-17 Rehabilitation Maintenance Certificate Form	Modified
DOL GOVT-1.docx Supplementary Document	2018-08-24
Privacy Act Systems - DOLESA-15.docx Supplementary Document	2018-08-24
2018 opm salary table -rus.pdf Supplementary Document	2018-08-24
Supporting Statement 1240-0012 (OWCP-17) August 18.docx Supporting Statement A	2018-08-24

IC Document Collections

IC ID	Document Title	Status
43809	Rehabilitation Maintenance Certificate Form	Modified

ICR Details

OMB Control No: 1240-0012	ICR Reference No: 201805-1240-007
Status: Active	Previous ICR Reference No: 201503-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Rehabilitation Maintenance Certificate
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: 02/14/2019
	Date Received in OIRA: 11/30/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2022	36 Months From Approved	02/28/2019
Responses	3,452	0	3,752
Time Burden (Hours)	575	0	625
Cost Burden (Dollars)	0	0	0

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Abstract: Form OWCP-17 serves as a bill submitted by the program participant or OWCP, requesting reimbursement of expenses incurred due to participation in an approved rehabilitation effort for the preceding four-week period of fraction thereof.

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Authorizing Statute(s): US Code: 5 USC 8121 Name of Law: Federal Employees’ Compensation Act
   US Code: 33 USC 939 Name of Law: Longshore and Harbor Workers’ Compensation Act
   US Code: 33 USC 908(g) Name of Law: Longshore and Harbor Workers’ Compensation Act
   US Code: 5 USC 8111 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:
	83 FR 29143	06/22/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 61682	11/30/2018
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
Rehabilitation Maintenance Certificate	OWCP-17	Rehabilitation Maintenance Certificate

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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	3,452	3,752	0	0	-300	0
Annual Time Burden (Hours)	575	625	0	0	-50	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: No

Burden Reduction Due to:

Short Statement: It is noted that there has been a slight change in the number of forms filed annually since the last OMB submission from 2015. The responses from the respondents decreased from 3,752 to 3,452. Accordingly, the burden hours decreased from 625 to 575 an adjustment of 50 hours. Minor revision to the form is noted below: Added a line/space to the OWCP Rehabilitation Specialist or Rehabilitation Counselor section to clarify who is required to sign the form. Changed the font in the fillable sections to improve readability.

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Annual Cost to Federal Government: $85,020

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 11/30/2018

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