Statement of Recovery Forms

Forms and Documents

Document Name	Status
Form CA-1122 Statement of Recovery Form and Instruction	Modified
Form CA-1108 Statement of Recovery Forms Form and Instruction	Modified
summary of changes for the 1108 and CA-1122.docx Supplementary Document	2018-11-19
Occupational Employment and Wages.docx Supplementary Document	2018-10-29
DOL GOVT-1.docx Supplementary Document	2018-10-29
2018 opm salary table -rus.pdf Supplementary Document	2018-10-29
BLS National Compensation Survey-2010.pdf Supplementary Document	2018-10-29
Supporting Statement 1240-0001 2018.docx Supporting Statement A	2018-11-19

IC Document Collections

IC ID	Document Title	Status
188783	Statement of Recovery Form and Instruction	Modified
13938	Statement of Recovery Forms Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0001	ICR Reference No: 201808-1240-001
Status: Active	Previous ICR Reference No: 201609-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Statement of Recovery Forms
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	938	0	842
Time Burden (Hours)	467	0	419
Cost Burden (Dollars)	249	0	219

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Abstract: These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.

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Authorizing Statute(s): US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8131 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 44910	09/04/2018
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: 2

IC Title	Form No.	Form Name
Statement of Recovery	CA-1122	Statement of Recovery
Statement of Recovery Forms	CA-1108	Statement of Recovery

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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	938	842	0	0	96	0
Annual Time Burden (Hours)	467	419	0	0	48	0
Annual Cost Burden (Dollars)	249	219	0	0	30	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 previously approved number of annual responses, 842, is being increased to 938, which represents an increase of 96. The adjustments in burden hours are due to an increase in the number of third-party claims. The currently approved number of hours is 419 and the requested number of hours is 467, an increase of 48. Likewise, costs burden is now estimated at $249 versus the previously approved $219 which represents an increase of $30.00. The increase in these numbers represent a fluctuation in the number of annual respondents.

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Annual Cost to Federal Government: $16,007

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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