Supporting Statement 1240-0015 2023_MN nmh clean version.

Claim for Continuance of Compensation (CA-12)

OMB Control Number 1240-0015

OMB Expiration Date: January 31, 2024

SUPPORTING STATEMENT FOR

Claim for Continuance of Compensation (CA-12)

OMB CONTROL NO. 1240-0015

This ICR seeks to extend this Information Collection Request.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

The Office of Workers’ Compensation Programs administers the Federal Employees’ Compensation Act. which provides for continuation of pay or compensation for work related injuries or disease that resulted from federal employment. Under 5 USC 8133 of the Act, eligible survivors of deceased employees receive compensation benefits on account of the employee's death. OWCP has to monitor death benefits for current marital status, potential for dual benefits, and other criteria for qualifying as a beneficiary under the law. Under 5 USC 8149, the Secretary of Labor may prescribe rules and regulations necessary for the administration and enforcement of this subchapter. Under CFR 10.414, the CA-12 is sent annually to beneficiaries in death cases to verify that their marital and/or beneficiary status has not changed to remain entitled to benefits.

References:

https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm

https://www.ecfr.gov/current/title-20/section-10.414

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The information provided is used by OWCP claims examiners to ensure that death benefits being paid are correct, and that payments are not made to ineligible survivors.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology (e.g., permitting electronic submission of responses) and the basis for the decision to adopt this means of collection. Also, describe any consideration of using information technology to reduce burden.

A respondent may upload electronically a completed form CA-12 (typed or printed) into an application known as the Employee Compensation Operations and Management Portal (ECOMP). This application eliminates mailing cost to the respondent and there is no cost to the general public.

Reference: https://www.ecomp.dol.gov/#

Alternatively, a respondent may access, download and complete the Form CA-12 (typed or printed) for mailing or faxed to OWCP .

Reference: http://www.dol.gov/owcp/regs/compliance/ca-12.pdf

Reference: http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

The information requested on the Form CA-12 is not duplicative of any information available elsewhere. The claimant/beneficiary is the only source of this information.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection does not have a significant impact on a substantial number of small entities.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

This form is sent once a year in each case where death benefits are being paid. If the information were not collected, or were collected less frequently, individuals who are no longer entitled to death benefits would continue to receive benefits, thereby creating overpayments of compensation.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary, trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

A Federal Register Notice inviting comment was published on August 7, 2023 [88 FR 52213]. Public comments were not received. OWCP has not consulted with the public for this specific ICR. We are in the process of reviewing all our ICR requirements and implementing procedures to comply with M-22-10.  We anticipate this process to be implemented by FY2024. 

9. Explain any decision to provide any payments or gifts to respondents, other than remuneration of contractors or grantees.

Respondents do not receive any gifts or payments to furnish the requested information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

All information contained in FECA claim files is fully protected under the Privacy Act in the system of records known as DOL/GOVT-1 (Office of Workers' Compensation Programs, Federal Employees' Compensation Act File).

Reference: http://www.dol.gov/sol/privacy/dol-govt-1.htm

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Provide estimates of the hour burden of the collection of information. The statement should:

Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.¹

If this request for approval covers more than one form, provide separate hour burden

estimates for each form.

Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Monetized Value of Respondent Time
CA-12	2, 894	1	2, 894	0.08333	241	$28.94	$6, 975.00

Number of Respondents & Responses: The number of respondents and responses (2,894) are derived from completed CA-12s received from beneficiaries of death benefits for the period 2020-2022.

Burden Hours: The CA-12 requires the respondent to provide the information on his or her marital status, as well as the marital and educational status of any dependent children. The respondent is able to simply fill out the form immediately, since the information requested would not require any research. Past experience with the use of this form indicates that it takes approximately 5 minutes (0.08333 hour) for each respondent to provide the requested information.

Thus, it is estimated that respondents will spend approximately 241 total burden hours which is calculated as follows.

The hours are calculated at 2,894 x 0.08333 response time = 241.15702 or 241 hours rounded.

Monetized Value of Respondent Time: The burden hours (241) are multiplied by $28.94², which amounts to a respondent time cost of $6, 974.54 or $6, 975.00 rounded.

$28.94 x 241 hrs. = $,6, 974.54 or $6, 975.00 rounded.

Reference: https://www.bls.gov/web/empsit/ceseeb8a.htm

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and start up cost component (annualized over its expected useful life); and (b) a

total operation and maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

There are no start-up costs. The only operation and maintenance cost is for postage and envelopes, which is based on $0.69 ($0.66 postage and $0.03 envelope). Of the 2,894 respondents, 2,247 or 78% responded by mail,³ and 647 or 22% responded using ECOMP.⁴ Thus, the total cost for mailed responses = $1,550.00.⁵

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

An average of 2,894 forms are reviewed on an annual basis by a Claims Examiner with an average grade GS-12/Step 6 and hourly pay rate of $46.30.

Review of this form averages approximately 15 minutes, or 0.25 of an hour, which amounts to $33,498.05 or $33,498.00 rounded (2,894 forms x .25 hr review x $46.30/hr = $33,498.05 or $33,498.00 rounded).

Reference: RUS_h.pdf (opm.gov)

Where a claimant is unable to download the CA-12 or requests the form to be mailed, OWCP will mail the form and incur mailing costs. OWCP mails an average of 407 forms a year and incurs a mailing cost of $280.83 or $281.00 rounded (407 forms x $0.69 postage and envelope = $280.83 or $281.00 rounded).

Description	Cost ($)
Review Cost	$33,498.00
Mailing Costs	$ 281.00
Annual ECOMP Contract Pricing Hosting	$ 8,143.006
TOTAL GOVERNMENT COST	$ 41,922.00

15. Explain the reasons for any program changes or adjustments.

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. Minor revisions were made to the Privacy Act and Public Burden Statements. The changes made to the Privacy Act and Public Burden Statements were for clarity and they represent no substantive change.

16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The information collected with this form will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

The OMB expiration date will be displayed.

18. Explain each exception to the certification statement.

There are no exceptions to certification.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS.

This information collection does not employ statistical methods.

1 Indicate the retention period for any recordkeeping requirements that pertain to the ICR.

2 As the wage category of the respondents is unknown, the hourly wage rate is based on the National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS as of July 2023.

3 2, 247 / 2,894 = 0.77643400138217 or 78% rounded.

4 647 / 2,894 = .22356599861783 or 22% rounded.

5 [$0.66 (postage) + $0.03 (envelopes)] x 2,247 (forms) = $1550.43 or $1,550.00 rounded.

6 The cost to the Federal Government to maintain ECOMP is $285,000.00 per year. There are 35 forms which require OMB approval which can be downloaded through ECOMP. These forms are CA-2a, CA-5, CA-5b, CA-7, CA-12, CA-15, CA-16, CA-17, CA-20, CA-40, CA-41, CA-42, CA-155, CA-278, CA-721, CA-722, CA-1027, CA-1031, CA-1032, CA-1074, CA-1087,CA-1090, CA-1108, CA-1122, CA-1143, CA-1305, CA-1331, CA-2231, OWCP-5a, OWCP-5b, OWCP-5c, OWCP-16, OWCP-17, OWCP-20, and OWCP-44. The ECOMP figure used was based on the average cost for each of those collections, or 1/35 of $285,000.00, which is $8,142.86, or $8,143.00 rounded.

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