Claim for Compensation by a Dependent Information Reports

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-1074 Letter to Parents in Death Claim Development	Form	Modified	Available
Form CA-1031 Letter to Dependents to Verify Claimant Support	Form	Modified	Available
Form CA-5b Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren	Form and Instruction	Modified	Available
Form CA-5 Claim for Compensation by Surviving Spouse and/or Children	Form and Instruction	Modified	Available
1240-0013 Supporting Statement--final.docx	Supporting Statement A	Uploaded 2023-05-01	Repair queued
81 Fed. Reg. 47418 (July 21, 2016).pdf	Supplementary Document	Uploaded 2023-04-10	Available
b-8 table average hourly and weekly earnings of production and nonsupervisory employees on nonprivate nonfarm payrolls, seasonally adjusted.docx	Supplementary Document	Uploaded 2023-02-17	Repair queued
20 cfr 10.7 etc.docx	Supplementary Document	Uploaded 2019-10-07	Repair queued
2023 OPM Salary Table Rus.pdf	Supplementary Document	Uploaded 2023-02-17	Repair queued
5 usc 8110 augmented compensation for dependents.docx	Supplementary Document	Uploaded 2023-04-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13841	Claim for Compensation by a Dependent Information Reports	Form	Modified	Letter to Parents in Death Claim Development
13841	Claim for Compensation by a Dependent Information Reports	Form	Modified	Letter to Dependents to Verify Claimant Support
13841	Claim for Compensation by a Dependent Information Reports	Form and Instruction	Modified	Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren
13841	Claim for Compensation by a Dependent Information Reports	Form and Instruction	Modified	Claim for Compensation by Surviving Spouse and/or Children
13841	Claim for Compensation by a Dependent Information Reports	Other-	Modified

ICR Details

OMB Control No: 1240-0013	ICR Reference No: 202302-1240-003
Status: Historical Active	Previous ICR Reference No: 202008-1240-047
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/12/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/09/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved	07/31/2023
Responses	1,241	0	933
Time Burden (Hours)	1,063	0	800
Cost Burden (Dollars)	556	0	541

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Abstract: The forms included in this information collection are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation from federal employees, as well as their dependents or survivors, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency.

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Authorizing Statute(s): US Code: 5 USC 8124 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8110 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8149 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:
	88 FR 7109	02/02/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 29949	05/09/2023
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 Compensation by a Dependent Information Reports	CA-5, CA-5b, CA-1031, CA-1074	Claim for Compensation by Surviving Spouse and/or Children ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren ,   Letter to Dependents to Verify Claimant Support ,   Letter to Parents in Death Claim Development

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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	1,241	933	0	0	308	0
Annual Time Burden (Hours)	1,063	800	0	0	263	0
Annual Cost Burden (Dollars)	556	541	0	0	15	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 estimated number of annual respondents (1,241) is an increase of (308) from the previous request of (933). The estimate in burden hours (1,063) is an increase of (263) from the previously approved (800). We attribute increase in burden due to postage and the number of COVID related claims.

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Annual Cost to Federal Government: $28,535

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: 05/09/2023

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