Claim for Continuance of Compensation (CA-12)
1240-0015
July 2017
Supporting Statement
Claim for Continuance of Compensation (CA-12)
OMB NO. 1240-0015
This ICR seeks OMB approval to revise the collection as outlined in item 15 of this supporting statement.
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 Office of Workers’ Compensation Programs administers the Federal Employees’ Compensation Act, 5 USC 8101 et seq. Under section 8133 of the Act, eligible dependents of deceased employees receive compensation benefits on account of the employee's death. OWCP has to monitor death benefits for current marital status, potential for dual benefits, and other criteria for qualifying as a dependent under the law. The CA-12 is sent annually to beneficiaries in death cases to ensure that their status has not changed and that they remain entitled to benefits. In most cases, it is a matter of ensuring that a surviving spouse or child is still living and has not married so as to make them ineligible. The CA-12 is established for this purpose under 20 CFR 10.414.
References:
https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm
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.
The information provided is used by OWCP claims examiners to ensure that death benefits being paid are correct, and that payments are not made to ineligible survivors.
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.
In accordance with the Government Paperwork Elimination Act (GPEA), the Form CA-12 is available on-line in a PDF fillable and printable format.
References:
http://www.dol.gov/owcp/regs/compliance/ca-12.pdf.
The CA-12 can also be accessed through DOL’s DFEC on-line forms library at http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm.
As this form is initiated by the Government Agency (OWCP), which is not by the general public and may require multiple signatures from different private and or public entities, it is not being considered for electronic filing.
However, to improve upon the capabilities for the public to submit DFEC documents, OWCP has developed an alternative to mailing of documents. This application, known as The Employee Compensation Operations and Management Portal (ECOMP) is internet based, and allows the users the ability to upload a completed form electronically into their respective case record. This application is available to the claimant, employing agency, and medical provider, as appropriate. There is no cost involved to the general public.
Reference: https://www.ecomp.dol.gov/#
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 the Form CA-12 is not duplicative of any information available elsewhere. The claimant/beneficiary is the only source of this information.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
This information collection does not have a significant impact on a substantial number of small 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.
This form is sent once a year in each case where death benefits are being paid. If the information were not collected, or were collected less frequently, individuals who were no longer entitled to death benefits would receive those benefits, thereby creating overpayments of compensation.
7. Explain any special circumstances.
There are no special circumstances for conducting this information 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.
A Federal Register Notice inviting comment on this collection of information was published in the Federal Register on April 5, 2017 [82FR16633]. Comments were not received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
Respondents do not receive any gifts or payments to furnish the requested information.
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: http://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 request to supply social security number information would be considered sensitive, but receipt of this number by OWCP is essential in properly determining entitlement to benefits under the Act.
12. 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 are 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 CA-12 requires the respondent to provide the information on his or her marital status, as well as the marital and educational status of any dependent children. The respondent is able to simply fill out the form immediately, since the information requested would not require any research. Past experience with the use of this form indicates that it will take approximately 5 minutes for each respondent to provide the information that is requested.
Based on actual usage, it is estimated that 3,552 forms will be used annually. At 5 minutes per form, that is 1/12 or .083 of an hour, .083 X 3,552 = 294.816 or 295 hours, rounded up. This number is based on the 3 year averages from CY 2014-CY 2016 of eligible beneficiaries in receipt of death benefits.
Because the wage category of most of the respondents is not known, we have estimated the cost of the burden hours using the National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS, or $21.80 per hour.
$21.80 X 295 hrs. = $6,431 = respondent burden hour cost.
Reference: https://www.bls.gov/web/empsit/ceseeb8a.htm
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
There are no start-up costs. The only operation and maintenance cost is for postage and envelopes. The response cost is $0.52 ($0.49 postage and $0.03 envelope) for responses sent by mail. Uploaded responses entail no additional cost. As a no cost option is available for claimants, the Agency has discounted the average per-response cost by 78 percent –the 2014 percentage U.S. households with a high speed Internet connection, according to the Census Bureau. $0.52 x 22% = $0.114. 3,552 responses at $0.1144 = $406.00
14. Provide estimates of annualized cost to the Federal government.
Time to review each form - 1/12 = .083 of an hour
Hourly wage of reviewer - $35.73 (GS-12/2)
Reference: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/RUS_h.pdf
Processing Costs: 3,552 X $35.73 X .083 = $10,533.77 or ($10,534 rounded up)
Mailing
Costs: ($0.49 postage + $.03 envelope) = $0.52 X 3,552 = $1,847.04
or $1,847 rounded down.
Total Federal Costs: Processing ($10,534) + Annual ECOMP Contract Pricing Hosting ($319,757) + Mailing Costs ($1,847) = $332,138
15. Explain the reasons for any program changes or adjustments reported in ROCIS.
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. The Department has reassessed the extent to which paper costs affect public burdens for this collection and determined those costs should be included; this accounts for a burden adjustment of $406.00. Revisions for the collection are not expected to affect public burdens.
Summary of revisions to the form
On page 1:
(1) Under Instructions to Beneficiaries
Currently reads: The information on this form will be used to determine your eligibility for continuing benefits. Your response to this information is required to retain your compensation benefits.
Revised: The information on this form will be used to determine your eligibility for continuing benefits. Your response to this information is required to retain your compensation benefits. Your benefits may be suspended if you fail to return this form within 30 days of the date of the request. (20 CFR 10.414)
(2) Give beneficiaries an option to electronically submit form once completed.
Currently reads: RETURN TO: U.S. DEPARTMENT OF LABOR
DFEC CENTRAL MAILROOM,
P.O. BOX 8300, LONDON, KY 40742-8300
Revised: RETURN TO: U.S. DEPARTMENT OF LABOR
DFEC CENTRAL MAILROOM,
P.O. BOX 8300, LONDON, KY 40742-8300
OR
You can electronically upload documents into your case using the Employees’ Compensation Operations and Management Portal (ECOMP). You can access ECOMP from any internet browser at: https://www.ecomp.dol.gov/. When you access the website, choose the "Upload Document" option. You will be asked to provide your case number, last name, date of birth and date of injury to upload a document. ECOMP will then provide you with a Tracking Number so that you can verify when OWCP has received your document. For more detailed information about this document submission feature, visit the ECOMP website and click "Help."
(3) Revised accommodation statement
Currently reads: 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.
Revised: 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.
On page 2:
(4) C (5)
Currently reads: Have any dependents you claim compensation for married since the death of the above named employee?
Revised: Have any dependents receiving compensation, married, turned 18 or left school if over 18 since the death of the above named employee?
(5) C (7)
Currently reads: Give the following information for each person you receive compensation for:
Revised: Give the following information for each person you receive compensation for or are aware may be receiving compensation on account of the employee’s death:
(6) Between (C) (7) and (D) (8), caption
Currently reads: This block is to be completed by parent, grandparent, or dependent physically incapable of self-support
On page 3:
(7) E-13
Currently reads: When and where was the marriage performed and what was the change in name, if any?
Revised: When and where was the marriage performed and what was the change in name, if any? How old were you at the time of marriage?
(8) F (Certification Statement)
Currently reads: I declare under the penalties of perjury that the information contained on this form is true and correct: and that I will immediately notify the Office of Workers' Compensation Programs of any changes in status.
Revised: I certify that the information provided above is true and accurate to the best of my knowledge and belief and that I will immediately notify the office of workers’ compensation programs of any changes in status. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.
(8) Deleted the requirement for a second witness
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.
The information collected with this form 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.
No exception to display of the expiration date is sought.
18. Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to certification.
B. Collections of Information Employing Statistical Methods
This information collection does not employ statistical methods.
| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |