TSA Claims Application

Forms and Documents

Document Name	Status
Form 95-109 Filing a Claim Form	Modified
privacy_pia_tsa_cms_009.pdf Supplementary Document	2018-11-20
DHSTSA 006 Correspondence and Matters Tracking System 75 FR 18863 4132010.pdf Supplementary Document	2015-07-08
DHSTSA 009 General Legal Records 68 FR 49496 8182003.pdf Supplementary Document	2015-07-08
28 CFR 14-2.pdf Supplementary Document	2015-07-08
1652-0039 TSAClaimsApp 30DN 83 FR 47367 (9.20.2018).pdf Supplementary Document	2018-11-20
1652-0039 TSAClaimsApp 60DN_83 FR 21788 (5.10.2018).pdf Supplementary Document	2018-11-20
1652-0039 TSAClaimsApp SS.docx Supporting Statement A	2018-11-20
Federal Tort Claims Act.pdf Supplementary Document	2009-08-21

IC Document Collections

IC ID	Document Title	Status
43964	Filing a Claim Form	Modified
234085	Submitting Payment Information Other-Letter	New

ICR Details

OMB Control No: 1652-0039	ICR Reference No: 201811-1652-002
Status: Active	Previous ICR Reference No: 201506-1652-002
Agency/Subagency: DHS/TSA	Agency Tracking No: 1652-0039
Title: TSA Claims Application
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: 09/18/2019
	Date Received in OIRA: 01/31/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	11,400	0	10,000
Time Burden (Hours)	5,300	0	5,000
Cost Burden (Dollars)	2,550	0	14,800

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Abstract: The TSA Claims, Outreach, and Debt Branch (CODB) requests to continue collection of certain information to investigate tort claims filed against TSA for property damage, property loss, personal injury, or death. TSA needs to collect certain information from claimants, in addition to that collected on the Standard Form 95, to investigate claims properly. TSA is seeking continued approval for two forms associated with this process.

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Authorizing Statute(s): US Code: 28 USC 1346(b), 1402(b), 2401(b), Name of Law: Federal Tort Claims 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 21788	05/10/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 47367	09/20/2018
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
Filing a Claim	95-109	Claim for Damage Injury or Death
Submitting Payment Information

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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	11,400	10,000	0	0	1,400	0
Annual Time Burden (Hours)	5,300	5,000	0	0	300	0
Annual Cost Burden (Dollars)	2,550	14,800	0	0	-12,250	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: There has been no program change to this collection of information since its previous OMB approval, but the total hours increased from 5,000 to 5,300 due to accounting for payment information requests time and 200 additional claims per year.

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Annual Cost to Federal Government: $181,078

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.     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: 01/31/2019

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