Statement of Recovery Forms

ICR 202109-1240-001

OMB: 1240-0001

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Supporting Statement A
2022-01-04
Supplementary Document
2021-11-15
Supplementary Document
2021-11-15
Supplementary Document
2021-11-15
IC Document Collections
ICR Details
1240-0001 202109-1240-001
Received in OIRA 201808-1240-001
DOL/OWCP
Statement of Recovery Forms
Extension without change of a currently approved collection   No
Regular 01/11/2022
  Requested Previously Approved
36 Months From Approved 02/28/2022
1,164 938
580 467
21 249

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.

US Code: 5 USC 8131 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
  
None

Not associated with rulemaking

  86 FR 50559 09/09/2021
87 FR 1439 01/11/2022
No

2
IC Title Form No. Form Name
Statement of Recovery CA-1122 Statement of Recovery
Statement of Recovery Forms CA-1108 Statement of Recovery

  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
No
No
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.

$7,735
No
    Yes
    Yes
No
No
No
No
Marcus Sharpless 202 693-0998 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/11/2022


© 2022 OMB.report | Privacy Policy