Notice of Recurrence

Forms and Documents

Document Name	Status
Form CA-2a Notice of Recurrence Form and Instruction	Modified
Supporting Statement 1240-0009 (CA-2a).docx Supporting Statement A	2020-10-30
60-day FRN (1240-0009) published.pdf Supplementary Document	2020-10-29
30-day FRN (1240-0009) published.pdf Supplementary Document	2020-10-29
Privacy Act System of Records - FEC.docx Supplementary Document	2020-10-29
Section 8149 for CA-2a 2020.docx Supplementary Document	2020-05-22
Supplemental Document 20 cfr 10.104 for omb 1240-0009 2020.pdf Supplementary Document	2020-05-22
dol-govt-1 2020.pdf Supplementary Document	2020-05-22
SALARY TABLE 2020-RUS.pdf Supplementary Document	2020-05-22
BLS National Average Weekly Wage for non-sup workers on private non-ag payrolls 2020.pdf Supplementary Document	2020-05-22

IC Document Collections

IC ID	Document Title	Status
13870	Notice of Recurrence Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0009	ICR Reference No: 202005-1240-006
Status: Received in OIRA	Previous ICR Reference No: 201703-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Recurrence
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/30/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	133	289
Time Burden (Hours)	67	145
Cost Burden (Dollars)	69	150

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Abstract: This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.

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Authorizing Statute(s): US Code: 5 USC 8149 Name of Law: FederaL Employment Compensation Act-Regulations
  

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 35955	06/12/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 68599	10/29/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Notice of Recurrence	CA-2a	Notice of Recurrence

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ICR Summary of Burden

	Total Request	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	133	289	0	0	-156	0
Annual Time Burden (Hours)	67	145	0	0	-78	0
Annual Cost Burden (Dollars)	69	150	0	0	-81	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 is no change in reporting requirements. The adjustment for this submission is due to a decrease in the number of claims since the last approval. Over the last three fiscal years (FY2017-2019) an average of 2,654 recurrences were submitted. a decrease of 3,116 claims per year (5,770 was the average figure in the previous ICR submission in 2017). In applying the 5% rule described in the discussion in Question #1 above towards the number of claims being submitted by claimants who have left federal employment, the number of claims submitted by this group during this period is 133 (5% of 2,654) versus the previous OMB submission of 289 (5% of 5, 700). There is a decrease of 156 claims (289-133) since the last OMB submission. The annual Information Collection Time Burden is 67 hours which is a decrease of 78 hours based on the previous reporting hours of 145. The requested annual cost burden in dollars is $69 ($0.52 x 133). The prior cost burden was $150.00. There is a decrease of $81.00.

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Annual Cost to Federal Government: $2,376

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: 10/30/2020

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