TSA Claims Application

Forms and Documents

Document Name	Status
Form SF 95 Filing a Claim Form	Modified
DHS_ALL_013 DHS Claims Records_73 FR 63987 (10.28.2008).pdf Supplementary Document	2022-02-02
DHS_ALL_017 DHS General Legal Records_76 FR 72428 (11.23.2011).pdf Supplementary Document	2022-02-02
privacy_pia_tsa_cms_009.pdf Supplementary Document	2022-02-02
28 CFR 14-2.pdf Supplementary Document	2015-07-08
1652-0039 TSAClaimsApp 30 DN_87 FR 6889 (2.7.2022).pdf Supplementary Document	2022-02-07
1652-0039 TSAClaimsApp 60 DN_86 FR 62563 (11.10.2021).pdf Supplementary Document	2022-02-02
1652-0039 TSAClaimsApp SS_2.7.2022.docx Supporting Statement A	2022-02-07
Federal Tort Claims Act.pdf Supplementary Document	2009-08-21

IC Document Collections

IC ID	Document Title	Status
43964	Filing a Claim Form	Modified
234085	Submitting Payment Information Other-Letter	Modified

ICR Details

OMB Control No: 1652-0039	ICR Reference No: 202202-1652-001
Status: Received in OIRA	Previous ICR Reference No: 201811-1652-002
Agency/Subagency: DHS/TSA	Agency Tracking No: 1652-0039
Title: TSA Claims Application
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: 02/17/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	09/30/2022
Responses	10,250	11,400
Time Burden (Hours)	4,708	5,300
Cost Burden (Dollars)	2,610	2,550

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Abstract: The TSA adjudicates tort claims under the authority of the Federal Tort Claims Act (FTCA) (28 U.S.C. §§ 1346(b), 1402(b), 2401(b), 2671-2680). To thoroughly examine tort claims against the agency, TSA needs to collect additional information from claimants. The respondents to this collection are typically the traveling public, but may include others who have contact with TSA operations at various locations. Submission of a claim is entirely voluntary and initiated by individuals. Claimants typically file a claim by submitting to TSA a Standard Form 95 (SF-95), Claim for Damage, Injury, or Death, a form prescribed by the Department of Justice and approved under OMB control number 1105-0008. Because TSA requires further clarifying information in order to thoroughly examine their claim, claimants are asked to complete a Supplemental Information page added to the SF-95. For example, the Supplemental Information identifies the airport at which the incident occurred and states, if applicable, whether the incident occurred at a passenger security screening checkpoint or a checked baggage screening location. If the claim involves checked baggage, the Supplemental Information page identifies whether any third parties handled the checked bag and whether a checked bag was delayed. This information enables the claims examiner to promptly initiate a thorough investigation into the alleged loss and significantly reduces the time required to process the claim. This information also assists with identifying whether the claim should be more appropriately processed under the Military Personnel and Civilian Employees’ Claims Act (MPCECA).

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Authorizing Statute(s): US Code: 28 USC 1346(b), 1402(b), 2401(b), Name of Law: Federal Tort Claims 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 62563	11/10/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 6889	02/07/2022
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
Filing a Claim	SF 95	TSA Claims,Outreach, and Debt Branch Tort Claim Package
Submitting Payment Information

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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	10,250	11,400	0	0	-1,150	0
Annual Time Burden (Hours)	4,708	5,300	0	0	-592	0
Annual Cost Burden (Dollars)	2,610	2,550	0	0	60	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 no change to this collection of information since previous OMB approval. However, the respondents and hour burden have decreased.

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Annual Cost to Federal Government: $191,579

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: 02/17/2022

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