Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-278 Claims for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards	Form and Instruction	Modified	Available
Form CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form and Instruction	Modified	Repair queued
Justification for Non material change. CA-278 1.30.2023 (006).docx	Supplementary Document	Uploaded 2023-02-01	Available
Justification for Non material change. CA-278 1.30.2023 (006).docx	Supplementary Document	Uploaded 2023-02-01	Repair queued
Justification for Non material change. CA-278.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-08-02	Available
Justification for Non material change. CA-278.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-08-02	Repair queued
81 Fed. Reg 47418 (July 21, 2016).pdf	Supplementary Document	Uploaded 2020-01-08	Available
81 Fed. Reg 47418 (July 21, 2016).pdf	Supplementary Document	Uploaded 2020-01-08	Repair queued
Supporting Statement 1240-0006 final.docx	Supporting Statement A	Uploaded 2022-08-02	Available
Supporting Statement 1240-0006 final.docx	Supporting Statement A	Uploaded 2022-08-02	Available
Occupational Employment Statistics 2018.docx	Supplementary Document	Uploaded 2019-11-27	Available
Occupational Employment Statistics 2018.docx	Supplementary Document	Uploaded 2019-11-27	Repair queued
5 usc 8147 2019.docx	Supplementary Document	Uploaded 2019-11-27	Available
5 usc 8147 2019.docx	Supplementary Document	Uploaded 2019-11-27	Repair queued
Salary Table Cleveland 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Available
Salary Table Cleveland 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Repair queued
CFR-2000-title20-vol1-sec61-104 for ca-278 mjs 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Available
CFR-2000-title20-vol1-sec61-104 for ca-278 mjs 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Repair queued
CFR-2016-title20-vol1-sec61-101 for ca-278 mjs 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Available
CFR-2016-title20-vol1-sec61-101 for ca-278 mjs 2019.pdf	Supplementary Document	Uploaded 2019-11-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13940	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form and Instruction	Modified	Claims for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards
13940	Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0006	ICR Reference No: 202301-1240-008
Status: Historical Active	Previous ICR Reference No: 202208-1240-002
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/01/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	07/31/2023	07/31/2023
Responses	812	0	812
Time Burden (Hours)	406	0	406
Cost Burden (Dollars)	7,742	0	7,742

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Abstract: Information collected using Form CA-278 will allow OWCP to consider requests filed by insurance carriers and self-insured that have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees' Compensation Fund. The program requests clearance by the expiration date of March 31, 2020. he No material/Nonsubstantive Change is requests that the address be revised on item 1 of the instructions of the form which requires that the completed form be sent to OWCP. The new Division is now noted as OWCP Division of Federal Employees', Longshore and Harbor Workers' Compensation (DFELHWC). The address on item should now be noted as Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation, Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA), PO Box 8311, London, KY 4072-

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Authorizing Statute(s): US Code: 5 USC 8147 Name of Law: The Federal Employees' Compensation Act
   US Code: 42 USC 1701 Name of Law: War Hazards Compensation Act (WHCA)
   US Code: 5 USC 8121 Name of Law: Claim
   US Code: 5 USC 8145 Name of Law: Administration
   US Code: 5 USC 8149 Name of Law: Regulations
  

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:
	85 FR 2149	01/14/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 17366	03/27/2020
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act	CA-278	Claims for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	812	812	0	0	0	0
Annual Time Burden (Hours)	406	406	0	0	0	0
Annual Cost Burden (Dollars)	7,742	7,742	0	0	0	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:

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Annual Cost to Federal Government: $19,228

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.     No

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: 02/01/2023

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