Claim for Continuance of Compensation (CA-12)

Forms and Documents

Document Name	Status
Form CA-12 Claim for Continuance of Compensation Form and Instruction	Modified
60-day FRN (1240-0015) 8.7.23.pdf Supplementary Document	2023-10-06
dol govt - 1.pdf Supplementary Document	2023-10-06
5 USC 8133.pdf Supplementary Document	2023-10-06
National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS as of April 2023.pdf Supplementary Document	2023-10-06
OPM Salary Table 2023. RUS.pdf Supplementary Document	2023-10-06
Supporting Statement 1240-0015 2023_MN nmh clean version..docx Supporting Statement A	2023-11-14

IC Document Collections

IC ID	Document Title	Status
13838	Claim for Continuance of Compensation Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0015	ICR Reference No: 202310-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202005-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Continuance of Compensation (CA-12)
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: 12/05/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2024
Responses	2,894	2,866
Time Burden (Hours)	241	239
Cost Burden (Dollars)	1,550	1,562

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Abstract: This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.

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Authorizing Statute(s): US Code: 5 USC 8133 Name of Law: Compensation in case of death
  

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 52213	08/07/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 84362	12/05/2023
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
Claim for Continuance of Compensation	CA-12	Claim for Continuance of Comp under the FECA (CA-12)

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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	2,894	2,866	0	0	28	0
Annual Time Burden (Hours)	241	239	0	0	2	0
Annual Cost Burden (Dollars)	1,550	1,562	0	0	-12	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 (2, 894) is an increase of (28) from the previous request of (2, 866). The estimate in burden hours (241) is an increase of (2) from the previously approved (239). While the increase in respondents is not substantial, we attribute the increase in death benefits to eligible beneficiaries to COVID related deaths. There were no changes to the form itself, however, revisions were made to the Privacy Act and Public Burden Statements

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Annual Cost to Federal Government: $41,922

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: 12/05/2023

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