Claim for Continuance of Compensation (CA-12)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-12 Claim for Continuance of Compensation	Form and Instruction	Unchanged	Available
Justifiction - CA-12.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-02-19	Available
CA-12 Claim for Continuance of Compensation Under the FECA.pdf	Supplementary Document	Uploaded 2020-02-18	Available
Privacy Act System of Records DOL GOVT-1.doc	Supplementary Document	Uploaded 2017-03-17	Available
Section 8133 for omb 1240-0015 2017.doc	Supplementary Document	Uploaded 2017-03-17	Available
Current Employment Statistics- CES (National)Average hourly and weekly earnings of production and nonsupervisory employees on private nonfarm payrolls by industry sector, seasonally.htm	Supplementary Document	Uploaded 2017-03-17	Available
Salary Table 2017-RUS.pdf	Supplementary Document	Uploaded 2017-03-17	Available
Supporting Statement 1240-0015 2017.doc	Supporting Statement A	Uploaded 2017-07-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13838	Claim for Continuance of Compensation	Form and Instruction	Unchanged

ICR Details

OMB Control No: 1240-0015	ICR Reference No: 202002-1240-004
Status: Active	Previous ICR Reference No: 201703-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Continuance of Compensation (CA-12)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/27/2020
	Date Received in OIRA: 02/21/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	10/31/2020	10/31/2020
Responses	3,552	0	3,552
Time Burden (Hours)	295	0	295
Cost Burden (Dollars)	1,847	0	1,847

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Abstract: Requesting address change. This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.

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Authorizing Statute(s): None

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:
	82 FR 16633	04/05/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 36179	07/31/2017
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 Continuance of Compensation	CA-12	Claim for Continuance of Compensation Under the Federal Employees' 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	3,552	3,552	0	0	0	0
Annual Time Burden (Hours)	295	295	0	0	0	0
Annual Cost Burden (Dollars)	1,847	1,847	0	0	0	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 are currently 3,552 individuals receiving death benefits vs. 4,083, which was reported in the previous OMB submission, a difference of 531 respondents. The annual Information Collection Time Burden (hours) is 295, which is a decrease of 44 hours based on the previous reporting hours of 339. The operation and maintenance costs associated with this submission is $1,847 (a decrease of $154.00 from the previous figures of $2,001) due to decreases in the number of respondents. Revisions to this ICR are not expected to alter the public burden.

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Annual Cost to Federal Government: $12,381

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: 02/21/2020

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