Request for Employment Information

Forms and Documents

Document Name	Status
Form CA-1027 Request for Employment Information Form and Instruction	Modified
2022 OPM Salary Table Rest of US.pdf Supplementary Document	2022-04-01
Table B-8. National Average Weekly Wage for Production or Nonsupervisory Workers on Private NonAgricultuarl Payrolls 2021.pdf Supplementary Document	2022-04-01
Section 8106 used in 2022.docx Supplementary Document	2022-04-01
Supporting Statement 1240-0047 (CA-1027) FINAL OCIO.docx Supporting Statement A	2022-05-23

IC Document Collections

IC ID	Document Title	Status
13773	Request for Employment Information Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0047	ICR Reference No: 202204-1240-001
Status: Received in OIRA	Previous ICR Reference No: 201902-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Employment Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/29/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2022
Responses	10	34
Time Burden (Hours)	3	9
Cost Burden (Dollars)	6	20

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Abstract: This information collection is used to collect information about a claimant's employment. It is necessary to determine continued eligibility for compensation payments under the Federal Employees' Compensation Act (FECA).

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Authorizing Statute(s): US Code: 5 USC 8106 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:
	87 FR 13331	03/09/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 38782	06/29/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Employment Information	CA-1027	Request for Employer 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	34	0	0	-24	0
Annual Time Burden (Hours)	3	9	0	0	-6	0
Annual Cost Burden (Dollars)	6	20	0	0	-14	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: The previously approved number of respondents has decreased from 34 to 10, which is a difference of 24. Consequently, burden hours have also decreased, which were previously noted as 9, now adjusted to 3, a difference of 6. The adjustments are resultant from a decrease in the number of claims for wage loss filed by former federal employees in which earnings information is sought from a private employer.

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Annual Cost to Federal Government: $161

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.     No

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: 06/29/2022

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