Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form and Instruction	Modified	Available
20 cfr 10.528.docx	Supplementary Document	Uploaded 2020-03-20	Available
DOL GOVT-1.docx	Supplementary Document	Uploaded 2020-03-20	Available
opm salary table 2020.pdf	Supplementary Document	Uploaded 2020-03-20	Available
Average hourly and weekly earnings of production and nonsupervisory employees on private nonfarm payrolls by industry sector, seasonally adjusted.docx	Supplementary Document	Uploaded 2020-03-20	Repair queued
5 USC Sections 8105, 8106, 8110, 8132 and 8148.docx	Supplementary Document	Uploaded 2020-03-20	Available
1240-0016 Supporting Statement final.docx	Supporting Statement A	Uploaded 2020-08-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13834	Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0016	ICR Reference No: 202003-1240-006
Status: Active	Previous ICR Reference No: 201701-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
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: 11/23/2020
	Date Received in OIRA: 08/19/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved	11/30/2020
Responses	37,056	0	45,161
Time Burden (Hours)	12,352	0	15,054
Cost Burden (Dollars)	15,030	0	5,166

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Abstract: Form CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

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Authorizing Statute(s): US Code: 5 USC 8101-8193 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:
	85 FR 18279	04/01/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 50838	08/18/2020
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
Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement

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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	37,056	45,161	0	0	-8,105	0
Annual Time Burden (Hours)	12,352	15,054	0	0	-2,702	0
Annual Cost Burden (Dollars)	15,030	5,166	0	0	9,864	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 annual respondents, 45, 161, 800 is now 37, 056, which represents a decrease of 8105. The previously approved number for burden hours was 15, 054 the requested number now is 12, 352, a decrease of 2, 702 hours.

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Annual Cost to Federal Government: $426,539

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? 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: 08/19/2020

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