Request for Employment Information

Forms and Documents

Document Name	Status
Form CA-1027 Request for Employment Information Form and Instruction	Modified
RUS_h opm salary table 2018.pdf Supplementary Document	2019-02-25
Table B-8 national average weekly wage for production or Nonsupervisory workers on private nonagricultural payrolls-2018.docx Supplementary Document	2019-02-25
Section 8106 used in 2019.doc Supplementary Document	2019-02-25
Supporting Statement 1240-0047 (CA-1027) 2019.docx Supporting Statement A	2019-05-07

IC Document Collections

IC ID	Document Title	Status
13773	Request for Employment Information Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0047	ICR Reference No: 201902-1240-002
Status: Active	Previous ICR Reference No: 201507-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Employment Information
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: 08/29/2019
	Date Received in OIRA: 05/31/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2022	36 Months From Approved	08/31/2019
Responses	34	0	154
Time Burden (Hours)	9	0	39
Cost Burden (Dollars)	20	0	74

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Abstract: This information collection is used to collect information about a claimant's employment. It is necessary to determine continued eligibility for compensation payments under FECA.

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Authorizing Statute(s): US Code: 5 USC 8106 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:
	84 FR 8344	03/07/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 25074	05/31/2019
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
Request for Employment Information	CA-1027	Request for Employer 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	34	154	0	0	-120	0
Annual Time Burden (Hours)	9	39	0	0	-30	0
Annual Cost Burden (Dollars)	20	74	0	0	-54	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 is a reduction in the number of respondents from the previous submission of 154 to 34, a decrease in 120. Accordingly, the previous cost burden amount of $74 is adjusted to $20 a decrease of $54. The previous burden hours of 39 is adjusted to 9, a difference of 30. The adjustments are resultant from a decrease in the number of claims for wage loss filed by former federal employees in which earnings information is sought from a private employer. There is only one revision to the letter with the accommodation statement which is found at the bottom of the letter. The current approved version reflects the following statement “If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims examiner for information about the kinds of help available, such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications.” The revision will reflect the following: “If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP.”

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Annual Cost to Federal Government: $446

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.     No

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: 05/31/2019

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