OPM1530_OMBSupportStmt_2020_09_28

OMB SUPPORTING STATEMENT

OPM Form 1530 – Report of Medical Examination of Person Electing Survivor Benefits under
the Civil Service Retirement System

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

Title 5, U. S. Code, Section 8339(k)(1) provides that an employee in good health who is applying for a non-disability annuity, may elect at the time of retirement, a reduced annuity in order to provide a survivor benefit for a person who has an insurable interest. An insurable interest exists if the survivor is a person who would suffer financially because of the death of the retiree.

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.

When an employee elects an insurable interest survivor annuity, the Office of Personnel Management requires that the applicant provide evidence of a recent medical examination to verify their good health. OPM Form 1530 is designed to collect information from both the applicant and the applicant’s physician regarding the applicant’s health. This information is used to determine whether the insurable interest survivor benefits election can be allowed. Specifically, solicitation of this information is also authorized by the Federal Employees Retirement System (Chapter 84, title 5, United States Code). The Privacy Act Statement has been revised due to a general systematic review by our Chief Privacy Officer and there are editorial changes to the display of OMB nomenclature. The Public Burden Statement meets the requirements of 5 CFR 1320.8(b)(3).

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.

The information collected is detailed and can only be obtained from the respondents. New methods of information technology would do little to reduce the burden on the respondents. However, this form is available in a pdf fillable format on our website and meets our GPEA requirements.

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 2 above.

Applications are filed individually. There is no duplication because the respondents initiate the collection.

5. If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize.

Information is not collected from small businesses.

6. Describe the consequence to Federal/DHS program or policy activities if the collection of information is not conducted, or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

The collection of this information is performed as needed to grant the survivor reduction to eligible persons. Less frequent collection would deny this benefit which is provided by law.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

•requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

•requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances that would cause this collection to be collected in the aforementioned manner. This collection is consistent with the guidelines of 5 CFR 1320.6.

8. Federal Register Notice: Provide a copy and identify the date and page number of the publishing in the Federal Register of the agency’s notice soliciting comments on the information collection prior to submission to OMB

A notice of proposed information collection was published in the Federal Register on, April 13, 2020, giving persons outside the agency an opportunity to comment on the forms. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to these respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

This information collection is protected by the Privacy Act of 1974 and OPM regulations
(5 CFR 831.106 and 5 CFR 841.108). The routine uses for disclosure appear in the Federal
Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008).

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 information collection does not include questions regarding sexual behavior and attitudes or religious beliefs, and other matters that are commonly considered private. However, the collection does include questions about the health and physical condition of the applicant because these matters are fundamental to the decision as to whether to allow the insurable interest survivor election.

12. Provide estimates of the hour burden of the collection of information. The statement should:

a. 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 conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desired. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

c. Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Approximately 500 annuitants apply to elect an insurable interest survivor annuity each year. The form requires approximately one hour and 30 minutes to complete. This includes the time needed to undergo a physical examination and enter the results on the form. A burden of 750 hours is estimated and is not expected to vary substantially.

Form Name	Form Number	No, of Respondents	No. of Responses per Respondent	Total Annual Burden (in hours)	Average Hourly Wage Rate	Total Annual Respondent Cost
Report of Medical Examination of Person Electing Survivor Benefits	OPM 1530	500	1	1.5 hours	$10.75	$6,718.75

The estimated Total Annual Respondent Cost is $6,718.75.

13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14.)

The cost estimate should be split into two components: (1) a total capital and start-up cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection as appropriate.

Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information to keep records for the government, or (4) as part of customary and usual business or private practices.

A physician’s report is required to document the state of the applicant’s health. There is no way to estimate the cost to the respondent because the respondent may or may not have had a recent physical examination on which to base the physician’s report.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing and support staff), and any other expense that would have been incurred without this collection of information. You may also aggregate cost estimates for Items 12, 13, and 14 in a single table.

The annualized cost to the Federal government is $24,150. This cost includes employee salary hours devoted to the program, forms cost, and overhead.

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I. Changes in hour burden, i.e., program changes or adjustments made to annual reporting and recordkeeping hour and cost burden. A program change is the result of deliberate Federal government action. All new collections and any subsequent revisions of existing collections (e.g., the addition or deletion of questions) are recorded as program changes. An adjustment is a change that is not the result of a deliberate Federal government action. These changes that result from new estimates or actions not controllable by the Federal government are recorded as adjustments.

There is no change to the respondent burden.

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 of information, completion of report, publication dates, and other actions.

The results of this information collection are not published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain reasons that display would be inappropriate.

The Retirement Services program office is the lone processor of the data collected on these ICRs from approximately 2.8 million customers. The substance of each information collection does not substantively change at each OMB renewal cycle, but according to changes in law and regulation. These forms are printed and published (internet, intranet and on-board systems) through various agencies for distribution to and implementation by Government customers. Pursuant to title 5 CFR 1320.8(b)(1), it would not be appropriate to display the OMB clearance expiration date where the form will not be revised for the foreseeable future (e.g., because it is used to collect applicant, annuitant, or beneficiary information required by long-standing statutory provisions), where use of the paper form is prevalent, and where, accordingly, it will be expensive and burdensome to restock the paper forms inventory with a new version. Last year, under current practice, Retirement Services printed approximately 2 million documents subject to OMB clearance at a cost of approximately $85,000. Our costs would rise substantially if additional revision cycles are added. Lastly, by adding the OMB clearance expiration date to the existing format, the end users of OPM’s ICRs may erroneously assume that the expiration date affects the validity of the information collection when it is the OMB clearance expiration date and not reflective of the substance. This may lead to additional submissions by customers, possible litigation and increasing pressures on our Operations workloads. Therefore, we seek approval to not display the OMB clearance expiration date on the forms and to communicate version changes to the public via the revision date.

18. Explain each exception to the certification statement identified in Item 19 “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

There are no exceptions to the certification statement.