Claim for Compensation by a Dependent Information Reports

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
1240-0013 Letter to Parents in Death Claim Development (CA-1074).pdf	Supplementary Document	Uploaded 2020-08-24	Available
1240-0013 Claim for Comp by Parents Brothers Sisters Grandparents or Grandchildren (CA5b).pdf	Supplementary Document	Uploaded 2020-08-24	Available
1240-0013 Claim for Comp by Surviving Spouse and or Children (CA-5).pdf	Supplementary Document	Uploaded 2020-08-24	Available
1240-0013 Letter to Dependents to Verify Claimant Support (CA-1031).pdf	Supplementary Document	Uploaded 2020-08-24	Available
Justification - OWCP Claim Forms (CA-5) (CA-5b) (CA-1031) and (CA-1074).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-08-24	Available
1240-0013 Spt Stmt final 06 2020.docx	Supporting Statement A	Uploaded 2020-07-02	Available
81 Fed. Reg 47418 (July 21, 2016).pdf	Supplementary Document	Uploaded 2020-01-08	Available
Employment Situation Summary Table B_ Establishment data, seasonally adjusted.htm	Supplementary Document	Uploaded 2019-10-07	Available
20 cfr 10.7 etc.docx	Supplementary Document	Uploaded 2019-10-07	Available
OPM Salary Table 2019.pdf	Supplementary Document	Uploaded 2019-10-07	Available
5 usc 8110 augmented compensation for dependents.docx	Supplementary Document	Uploaded 2019-10-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13841	Claim for Compensation by a Dependent Information Reports	Other-null	Modified

ICR Details

OMB Control No: 1240-0013	ICR Reference No: 202008-1240-047
Status: Active	Previous ICR Reference No: 201910-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
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: 10/23/2020
	Date Received in OIRA: 10/20/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	07/31/2023	07/31/2023
Responses	933	0	933
Time Burden (Hours)	800	0	800
Cost Burden (Dollars)	541	0	541

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Abstract: OWCP is requesting an address change to the Letter to Dependents to Verify Claimant Support (CA-1031), Claim for Compensation by Surviving Spouse and/or Grandchildren (CA-5), Claim for Compensation by Parents, Brothers, Sisters, Grandparents or Grandchildren (CA-5b) and the Letter to Parents in Death Claim Development (CA-1074). The forms included in this package are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation from federal employees/ their dependents/ survivors, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency.

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Authorizing Statute(s): US Code: 5 USC 8124 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8110 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8149 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:
	84 FR 60457	11/08/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 21025	04/15/2020
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
Claim for Compensation by a Dependent Information Reports	CA-5, CA-5b, CA-1031, CA-1074	Claim for Compensation by Surviving Spouse and/or Children ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren ,   Letter to Dependents to Verify Claimant Support ,   Letter to Parents in Death Claim Development

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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	933	933	0	0	0	0
Annual Time Burden (Hours)	800	800	0	0	0	0
Annual Cost Burden (Dollars)	541	541	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:

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Annual Cost to Federal Government: $13,837

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: 10/20/2020

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