Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form and Instruction	Modified	Available
81 Fed. Reg 47418 (July 21, 2016).pdf	Supplementary Document	Uploaded 2020-01-08	Available
Supporting Statement 1240-0006 final.docx	Supporting Statement A	Uploaded 2020-03-20	Available
Occupational Employment Statistics 2018.docx	Supplementary Document	Uploaded 2019-11-27	Available
5 usc 8147 2019.docx	Supplementary Document	Uploaded 2019-11-27	Available
Salary Table Cleveland 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Available
CFR-2000-title20-vol1-sec61-104 for ca-278 mjs 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Available
CFR-2016-title20-vol1-sec61-101 for ca-278 mjs 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13940	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0006	ICR Reference No: 201911-1240-005
Status: Active	Previous ICR Reference No: 201609-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2020
	Date Received in OIRA: 03/27/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved	07/31/2020
Responses	812	0	345
Time Burden (Hours)	406	0	173
Cost Burden (Dollars)	7,742	0	542

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Abstract: Information collected using Form CA-278 will allow OWCP to consider requests filed by insurance carriers and self-insured that have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees' Compensation Fund. The program requests clearance by the expiration date of March 31, 2020.

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Authorizing Statute(s): US Code: 5 USC 8147 Name of Law: The Federal Employees' Compensation Act
   US Code: 42 USC 1701 Name of Law: War Hazards Compensation Act (WHCA)
   US Code: 5 USC 8121 Name of Law: Claim
   US Code: 5 USC 8145 Name of Law: Administration
   US Code: 5 USC 8149 Name of Law: Regulations
  

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:
	85 FR 2149	01/14/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 17366	03/27/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	CA-278	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

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ICR Summary of Burden

table that charts list 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	812	345	0	0	467	0
Annual Time Burden (Hours)	406	173	0	0	233	0
Annual Cost Burden (Dollars)	7,742	542	0	0	7,200	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 previous approved number of 345 is now 812, which an increase of 467. Due to the increase in the number of respondents, the previously approved number of burden hours (173), is now (406), an increase of 233. The costs burden increased from $542 to $7,742, which is an adjustment of $7,200. Previously, this figure was based on operational and mailing costs incurred by the respondent. This figure now shows the monetized value of respondents time which is matched with the annual cost burden figure, which explains this significant increase.

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Annual Cost to Federal Government: $19,228

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.     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? No

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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: 03/27/2020

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