Claim for Continuance of Compensation (CA-12)
1240-0015
Supporting Statement
Claim for Continuance of Compensation (CA-12)
OMB NO. 1240-0015
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. which provides for continuation of pay or compensation for work related injuries or disease that resulted from federal employment. Under 5 USC 8133 of the Act, eligible survivors 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 beneficiary under the law. Under 5 USC 8149, the Secretary of Labor may prescribe rules and regulations necessary for the administration and enforcement of this subchapter. Under CFR 10.414, the CA-12 is sent annually to beneficiaries in death cases to verify that their marital and/or beneficiary status has not changed to remain entitled to benefits.
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.
Reference: 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.
Additionally, 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 2020 [FR]. 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 2866 forms will be used annually. At 5 minutes per form, that is 1/12 or .08333 of an hour. 08333 hours X 2866 forms = 239 hours. This number is based on the 3 year averages from FY-2017 through FY-2019 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 $23.88 per hour.1
$23.88 x 239 hrs. = $5,703.00 = respondent burden hour cost
Reference: https://www.bls.gov/web/empsit/ceseeb8a.htm
Estimated Annualized Respondent Cost and Burden Hours
Form # |
Annual # of Respondents |
Total Number of Responses |
Average burden per response (in hours) |
Annual estimated burden hours |
Average Hourly Wage |
Annual Monetized burden hours |
CA-12 |
2866 |
1 |
.08333 |
239 |
$23.88 |
$5,703.00 |
Total |
2866 |
1 |
.08333 |
239 |
$23.88 |
$5,703.00 |
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 $0.58 ($0.55 postage and $0.03 envelope) for responses sent by mail. However, electronically uploaded responses using ECOMP is 2.6% and responses sent via facsimile is 3.8%, for an average of 6% (rounded down), and entail no additional cost. The total cost for the 94% mailed, is calculated as $1,562.00, as noted in the chart below.
Respondent Cost Table-CA-12
[$0.55 (postage) + $0.03 (envelopes)] x (2,866) (forms) = $1, 662.00
Total Combined Costs $1,662.00 x 94% (mailed response) = $1,562.00
14. Provide estimates of annualized cost to the Federal government.
Time to review each form - 1/12 = .08333 of an hour
Hourly wage of reviewer - $ 42.89 (GS-12/6)
https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2020/RUS_h.pdf
Processing Costs: 2,866 X 42.89 X .08333 = $10,243.00
Mailing Costs: ($0.55 postage + $.03 envelope) = $0.58 X 2866 = $ 1,662.00
Total Federal Costs: Processing ($10,243.00) + Annual ECOMP Contract Pricing Hosting ($7,714.00)2 + Mailing Costs ($1,662.00 ) = $19,619.00
15. Explain the reasons for any program changes or adjustments reported in ROCIS.
There are currently 2,866 individuals receiving death benefits vs. 3,552, which was reported in the previous OMB submission, a difference of 686 respondents. The annual Information Collection Time Burden is 239 hours which is a decrease of 56 hours based on the previous reporting hours of 295.
Summary of Revisions to the Form
Effective April 27, 2020, OWCP changed its address for receipt of general correspondence from London, Ky to San Antonio, TX, This change is noted in the instructions of the form.
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.
1 This average hourly wage is based on the most recent non-preliminary data, January 2020.
2 The ECOMP cost is $270,000 for FY 2019. There are 35 forms which require OMB approval which can be downloaded through ECOMP. These forms are CA-2a, CA-5, CA-5b, CA-7, CA-12, CA-15, CA-16, CA-17, CA-20, CA-40, CA-41, CA-42, CA-155, CA-278, CA-721, CA-722, CA-1027, CA-1031, CA-1032, CA-1074, CA-1087,CA-1090, CA-1108, CA-1122, CA-1143, CA-1305, CA-1331, CA-2231, OWCP-5a, OWCP-5b, OWCP-5c, OWCP-16, OWCP-17, OWCP-20, and OWCP-44. The ECOMP figure used was based on the averaged cost for each of those collections, or 1/35 of $270,000, which is $7,714.29, $7,714, rounded down.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT |
| Author | US Department of Labor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |