1240-0022 Supporting Stmt

1240-0022

Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death

March 2020

SUPPORTING STATEMENT

Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA-721) and Notice of Law Enforcement Officer’s Death (CA-722)

OMB No. 1240-0022

A. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

The Federal Employees' Compensation Act (FECA) provides, under 5 U.S.C. 8191, et.seq. and 20 CFR 10.735, that non-Federal law enforcement officers injured or killed under certain circumstances are entitled to the benefits of the Act, to the same extent as if they were employees of the Federal Government. The CA-721 and CA-722 are used by non-Federal law enforcement officers and their survivors to claim compensation under the FECA. Form CA-721 is used for claims for injury. Form CA-722 is used for claims for death. The authority for this collection is 5 U.S.C. § 8191-8193.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

These forms are the device by which notices of injury, claims for compensation, and claims for death benefits are filed by non-Federal law enforcement officers and their survivors. The information contained in the forms is used to help determine if the case is covered and what further issues to develop. For example, was the injury sustained under circumstances bringing it within 5 U.S.C. 8191, was the injury disabling, is the disability due to the injury, are those filing a claim entitled to compensation, what further information is required to reach a decision, etc.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden. 

Due to the low usage of the forms associated with this OMB collection, we believe it sufficient that they be electronically filled only, rather than submitted electronically completed and filed for submission. They may be downloaded, printed, and submitted by mail or facsimile to DFEC. The forms CA-721 and CA-722 can be completed on-line, printed and are available for downloading from the Internet at

Reference: https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

Note: Please note that once a CA-721/ CA-722 has been received and created by DFEC, users may use an application, known as Employee Compensation Operations and Management Portal (ECOMP), which is internet base and allows the user the option to upload documents electronically as an alternative to mailing/faxing documents into their respective case record. This application is available to the claimant, beneficiary, employing agency, and the medical provider, as applicable. There is no cost.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

The information requested on these forms is not duplicative of any information available elsewhere. The claimant, beneficiary, employer, and physician are the only sources of the required information.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The only involvement of small businesses is physicians who complete the medical documentation portion of the form. This information collection does not have a significant economic impact on a substantial number of small business entities.

6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

 

The information is collected only once. Without the requested information, no determination could be made regarding the payment of benefits.

7. Explain any special circumstance.

There are no special circumstances impacting this collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.

No outside consultants were contacted concerning the use of forms CA-721 and CA-722.

A notice inviting public comment on this information collection was published in the Federal Register on January 24, 2020, 2019 (85 FR 4341). Comments were not received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gifts are provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

All information contained in FECA claim files is fully protected under the Privacy Act in the system of records known as DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal Employees' Compensation Act File)

Reference: https://www.dol.gov/sol/privacy/dol-govt-1.htm

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

The CA-721 and CA-722 include a Privacy Act statement that defines when and for what purposes may be disclosed, The Privacy Act Statements on the forms will read as follows:

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

We are authorized to request a taxpayer identification number (TIN) or Social Security Number (SSN) under the Debt Collection Improvement Act of 1996, Title 31 U.S.C. amended section 7701(c) (1), which mandates us to require regulated entities and persons who are doing business with a Federal agency to furnish a TIN or SSN. The SSN or TIN, and other information maintained by the Office, maybe used for identification, to support debt collection efforts, carried on by the Federal government and for other purposes required or authorized by law.

12. Provide estimates of the hour burden of the collection of information. The statement should:

Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information.

The response times below were based on the length of time that it will take respondents to complete the forms and obtain the necessary information. Both require full explanations of how injury or death occurred, the federal crime involved, etc.

Activity	Number of Respondents	Frequency	Total Annual Responses	Time Per Response	Total Annual Burden (Hours)	Hourly Rate*	Monetized Value of Respondent Time
CA-721	6	1	6	1.	6	$14.50	$87.00
CA-722	0	0	0	0	0	$0.00	$0.00
Totals	6		6	1.	6	$14.50	$87.00

Note: There were no newly created CA-722s filed during calendar years 2016-2018.

The combined burden costs have been calculated to be $87 ($14.50 X 6) = $87.00

Note: As the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage median wages of productions workers as computed by BLS, or $14.50 per hour ($14.50 X 6 hours = $87.00)

Reference: http://www.bls.gov/oes/current/oes519199.htm

13. Annual Costs to Respondents (capital/start-up & operation and maintenance). 

There is no capital/startup or ongoing operation/maintenance costs associated with this information collection. Operation and maintenance costs consist solely of mailing costs, which equates to $3.00. Six (6) annual responses x ($0.55 for postage + $0.03 for an envelope) = 6 x .58 = $3.50 or $4.00 rounded up.

14. Provide estimates of annualized cost to the Federal government.

Review Costs:

All claims are reviewed and adjudicated by a staff of six Claims Examiners located in the Cleveland district office. (4) GS 12, Step 10; (1) GS-12, Step 6; and (1) GS-13, Step 10, with hourly salaries of $47.57; 42.69; and $56.57, respectively.

Therefore, the average hourly salary of the six examiners is $48.26

Average hourly wage = $48.26 ($47.57 x 4 + $42.69 +$56.57) = 289.54 divided by 6.

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/CLE_h.pdf

Six (6) forms X 1/3 of an hour each X $48.26 = $96.52 or $97 rounded up.

Federal Cost Estimate:

Printing Costs: Due to the small number of claims received, there are no plans to print the form in bulk for distribution.

Mailing and Developmental Costs: Claimants and employers are able to download forms CA-721 and CA-722 directly from the internet; therefore, no mailing costs for the forms will be incurred. However, development usually occurs in these types of cases, therefore, mailing costs for development of the claim = $3.00 ($.55 postage and $.03 for envelope per response) 6 x $.58 = $3.50, or $4.00 rounded up.

The total Federal cost for mailing and processing of these documents is $100.50 ($97.00 + $3.50) or $101.00 rounded up.

15. Explain the reasons for any program changes or adjustments.

The previous approved number of annual respondents (7) is now 6, which represents a decrease of 1. The previously approved number for burden hours was 9, and the requested number now is 6, a decrease of 3. All of the initial claims submitted for calendar years 2016-2018 were for claimed injuries or occupational diseases. The decrease in annual respondents is because no death claims were created for calendar years 2016-2018.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

 

Data collected with these forms will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate

The form will display the expiration date.

18. Explain each exception to the certification statement in ROCIS.

There are no exceptions to certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

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