Statement of Recovery Forms

Forms and Documents

Document Name	Status
Form CA-1122 Statement of Recovery Form and Instruction	Modified
Form CA-1108 Statement of Recovery Forms Form and Instruction	Modified
Supporting Statement 1240-0001 Clean 1.4.22.docx Supporting Statement A	2022-01-04
owcp feca privacy act system of records.docx Supplementary Document	2021-11-15
bls current employment statistics august 2020.docx Supplementary Document	2021-11-15
May 2020 Occupational Employment Statistics.docx Supplementary Document	2021-11-15

IC Document Collections

IC ID	Document Title	Status
188783	Statement of Recovery Form and Instruction	Modified
13938	Statement of Recovery Forms Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0001	ICR Reference No: 202109-1240-001
Status: Received in OIRA	Previous ICR Reference No: 201808-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Statement of Recovery Forms
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: 01/11/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2022
Responses	1,164	938
Time Burden (Hours)	580	467
Cost Burden (Dollars)	21	249

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Abstract: These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.

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Authorizing Statute(s): US Code: 5 USC 8131 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 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:
	86 FR 50559	09/09/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 1439	01/11/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Statement of Recovery	CA-1122	Statement of Recovery
Statement of Recovery Forms	CA-1108	Statement of Recovery

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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	1,164	938	0	0	226	0
Annual Time Burden (Hours)	580	467	0	0	113	0
Annual Cost Burden (Dollars)	21	249	0	0	-228	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 has been an increase in the number of respondents, FY2018–FY2020, due to an increase in the number of third-party claims. Accordingly, the previously approved number of annual responses, 938 is being increased to 1,164, which represents a difference of 226. The adjustments in burden hours are due to the increase in the number of third-party claims. The currently approved number of hours is 467 and the requested number of hours is 580 , an increase of 113.

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Annual Cost to Federal Government: $7,735

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: 01/11/2022

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