Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form and Instruction	Modified	Available
Updated Average hourly and weekly earnings of production and nonsupervisory employees.pdf	Supplementary Document	Uploaded 2023-09-12	Repair queued
ECOMP 1032 PART B Volunteer work.updated.docx	Supplementary Document	Uploaded 2023-09-12	Missing upstream
5 USC 8105, 8106, 8110, 8132, and 8148.docx	Supplementary Document	Uploaded 2023-07-21	Repair queued
20 CFR 10.528.docx	Supplementary Document	Uploaded 2023-07-21	Repair queued
DOL GOVT-1.docx	Supplementary Document	Uploaded 2023-07-21	Repair queued
Rest of U.S. OPM Salary Table. 2023.pdf	Supplementary Document	Uploaded 2023-06-30	Missing upstream
ECOMP 1032 Part H Certification .docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032 Part G Corrections .docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032 Part F Fraud Offenses.docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032. Part E Third-Party Settlement .docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032. Part D Other Federal Benefits or Payments .docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032. Part C Dependents .docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032. Part A Employment .docx	Supplementary Document	Uploaded 2023-04-26	Repair queued
ECOMP 1032 Print Screen Shots.docx	Supplementary Document	Uploaded 2023-04-26	Missing upstream
1240-0016 Supporting Statement .5.22.23 mjs 5.26.23_MN.updated 9.19.23_MN,clean copy.docx	Supporting Statement A	Uploaded 2023-09-19	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13834	Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0016	ICR Reference No: 202306-1240-003
Status: Received in OIRA	Previous ICR Reference No: 202304-1240-010
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
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: 09/25/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2023
Responses	33,372	37,056
Time Burden (Hours)	11,013	12,228
Cost Burden (Dollars)	15,198	15,030

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Abstract: Form CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

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Authorizing Statute(s): US Code: 5 USC 8116 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8148 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8110 Name of Law: Federal Employees' Compensation Act
   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:
	88 FR 37288	06/07/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 65755	09/25/2023
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
Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement

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ICR Summary of Burden

table that charts list 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	33,372	37,056	0	0	-3,684	0
Annual Time Burden (Hours)	11,013	12,228	0	0	-1,215	0
Annual Cost Burden (Dollars)	15,198	15,030	0	0	168	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 previous approved number of annual respondents, 37,056 is now 33,372 which represents a decrease of 3,684. The previously approved number for burden hours was 12,228 the requested number now is 11,013, a decrease of 1,215 hours.

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Annual Cost to Federal Government: $416,449

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: 09/25/2023

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