1240-0022 Supporting Statement_FINAL_20230905

Notice of Law Enforcement Officer’s Injury or Occupational Disease and Notice of Law Enforcement Officer’s Death

OMB Control Number: 1240-0022

OMB Expiration Date: October 31, 2023

SUPPORTING STATEMENT FOR

Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA-721); and Notice of Law Enforcement Officer’s Death (CA-722)

OMB CONTROL NO. 1240-0022

This ICR seeks to extend this information collection.

A. 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 Federal Employees’ Compensation Act (FECA) provides, under 5 U.S.C. 8191, et.seq. and 20 CFR 10.735, that non-Federal law enforcement officers injured or killed under certain circumstances are entitled to the benefits of the Act, to the same extent as if they were employees of the Federal Government. The CA-721 and CA-722 are used by non-Federal law enforcement officers and their survivors to claim compensation under the FECA. Form CA-721 is used for claims for injury. Form CA-722 is used for claims for death. The authority for this collection is 5 U.S.C. 8191-8193.

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.

These forms are the device by which notices of injury, claims for compensation, and claims for death benefits are filed by non-Federal law enforcement officers and their survivors. The information contained in the forms is used to help determine if the claim is covered and what further issues to develop: a) was the injury sustained under circumstances bringing it within 5 U.S.C. 8191; b) was the injury disabling; c) is the disability due to the injury; d) are those filing a claim entitled to compensation; e) what further information is required to reach a decision, etc.

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.

The CA-721/CA-722 are not submitted electronically because our electronic filing system, ECOMP, has not yet been updated to accept electronic filing of these forms.  Resource availability and budget constraints limit the number of forms we can create within ECOMP.  Further, the law enforcement entities who complete these forms are not federal agencies; only federal agencies have access to claim filing in ECOMP at this time. The forms CA-721 and CA-722 can be completed on-line, printed and are available for downloading from the Internet at: https://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 these forms is not duplicative of any information available elsewhere. The claimant, beneficiary, employer, and physician are the only sources of the required information.

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

The only involvement of small businesses is physicians who complete the medical documentation portion of the form. This information collection does not have a significant economic impact on a substantial number of small business 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.

 

The information is collected only once. Without the requested information, no determination could be made regarding the payment of benefits.

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 notice inviting public comment on this information collection was published in the Federal Register on 05-08-2023 (88 FR 29696). Comments were/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 FY-2024. 

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

No payment or gifts are provided to respondents.

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

The CA-721 and CA-722 include a Privacy Act statement that defines when and for what purposes the information may be disclosed. The Privacy Act Statements on the forms reads as follows:

The Privacy Act of 1974 as amended, (5 U.S.C. 552a), and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C 8101, et. seq) authorizes collection of this information. The information will be used to determine continuing entitlement to benefits. Furnishing the requested information is required for a claimant to obtain or retain a benefit. Failure to provide the information may result in the delay of a claim or payment of benefits, or may result in an unfavorable in a delay of a claim or payment of benefits, or result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: (1) to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (2) to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (3) to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (4) to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (5) to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act.

Reference: https://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.

Under the Debt Collection Improvement Act of 1996, Title 31 U.S.C. amended section 7701(c)(1), the DOL shall require persons doing business with it to furnish such person’s taxpayer identification number (TIN) or Social Security Number (SSN). The SSN or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts, carried on by the Federal government and for other purposes required or authorized by law.

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	Number of Respondents	Frequency	Total Annual Responses	Time Per Response (Hours)	Total Annual Burden (Hours)	Hourly Rate*	Monetized Value of Respondent Time
CA-721	1	1	1	1.	1	$15.83	$16.00
CA-722	1	1	1	1.50	1.5	15.83	$24.00
Totals	2		2		3	$15.83	$40.00

Burden Hours: Burden hour estimates are derived from estimated actual respondent usage of this form. It is estimated that it will take approximately 3 (2.5 rounded up) total burden hours to prepare both forms:

CA-721: 1 response X 1 hour = 1 burden hour

CA-722: 1 response X 1.5 hour = 1.5 burden hours

Total Burden Hours: 1 + 1.5 = 2.5 hours, or 3 hours rounded

Monetized Value of Respondent Times:

For the CA-721, the wage category of the respondent is unknown. Using the National Average Weekly Wage median wage of production workers as computed by the Bureau of Labor Statistics (BLS), this figure is $15.83.² Using the burden hour formula for the form, the monetized amount is computed as follows: 1 response x hourly burden (1) x hourly rate of $15.83, which equates to $15.83.

For the CA-722, the wage category of the respondent is unknown. Using the formula above, the estimated cost of burden hours using the National Average Weekly Wage median wages of production workers as computed by BLS is $15.83. Using the burden hour for the form, the monetized amount is computed as follows: 1 response x hourly burden (1.5) x $15.83 = $23.745 or $24.00 rounded.

The combined respondent annualized cost for this collection is $40.00, ($16.00 +$24.00).

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, 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 is no capital/startup or ongoing operation/maintenance costs associated with this information collection. Operation and maintenance costs consist solely of mailing costs, which equates to $1.38 or $1.00 rounded. (2 annual responses x ($0.66 for postage + $0.03 for an envelope) = 2 x .69 = $1.38 or $1.00 rounded.)

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), and 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.

The only costs to the Federal Government associated with these collections are Review Costs. It takes our Claims Examiners 20 minutes (0.333 hour), on average, to review each form. Our staff of six Claims Examiners earn an average hourly rate of $51.64.³ See OPM 2023 General Schedule Locality Pay Tables: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2023/general-schedule.

Given the above-estimated one response per collection, two responses total, the Total Review Cost to the Federal Government is: 2 Responses x 0.333 hour review time x $51.64/hour = $34.39224 or $34.00 rounded).

Total Review Cost Estimate

Collection	Number of Respondents	Time to Review (hours)	Claims Examiner Average Hourly Rate	Review Cost (rounded)
CA-721	1	0.333	$51.64	$17.00
CA-722	1	0.333	$51.64	$17.00
Totals	2	0.666		$34.00

Total Federal Cost Estimate: As the only cost to the Federal Government for this collection is Review Costs, the Total Federal Cost Estimate is $34.00 (rounded).

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

The previously approved number of annual respondents (6) is now 2, which represents a decrease of 4. The previously approved number for burden hours was 6, and the requested number now is 3, a decrease of 3. The number of these claims will remain low as jurisdictions are using less non-federal law enforcement officers to assist in circumstances involving a crime against the United States. While there are no changes to either form, we did revise the Privacy Act and Burden Statements.

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.

Data collected with these forms 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 form will display the expiration date.

18. Explain each exception to the certification statement.

There are no exceptions to the certification statement.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in these collections of information.

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

2 Reference: http://www.bls.gov/oes/current/oes519199.htm

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Claims Examiner Location	General Pay Schedule Grade & Step		Corresponding General Schedule Table Pay Rate (hourly salary)
Parma Heights, OH (Cleveland)	12, 2		$ 42.84
Jacksonville, FL (Rest of US)	12, 3		$ 42.33
Locust Grove, GA (Atlanta)	12, 7		$ 50.29
Medina, OH (Cleveland)	12, 9		$ 52.51
Weston, MA (Boston)	12, 10		$ 58.04
Walnut Creek, CA (San Francisco)	12, 10		$ 63.84
Claims Examiner Average Pay			$ 51.64 *

*($42.84 + $42.33 + $50.29 + $52.51 + $58.04 + $63.84) / 6 = $51.64

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