Supporting Statement for 1215-0154 (CA-12) November 2007

Supporting Statement

Claim for Continuance of Compensation (CA-12)

OMB NO.1215-0154

A. Justification.

1. The Office of Workers’ Compensation Programs administers the Federal Employees’ Compensation Act, 5 USC 8133. Under the Act, eligible dependents 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 dependent under the law. The CA-12 is sent annually to beneficiaries in death cases to ensure that their status has not changed and that they remain entitled to benefits. In most cases, it is a matter of ensuring that a widow, widower, or child is still living and has not married so as to make them ineligible. The CA-12 is established for this purpose under 20 CFR 10.414.

http://www.access.gpo.gov/uscode/title5/partiii_subpartg_chapter81_subchapteri_.html

http://www.access.gpo.gov/nara/cfr/waisidx_07/20cfr10_07.html

2. 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. In accordance with the Government Paperwork Elimination Act (GPEA), the Form CA-12 is available on-line in a PDF fillable and printable format at http://www.dol.gov/esa/regs/compliance/owcp/ca-12.pdf. The CA-12 can also be accessed through DOL’s DFEC on-line forms library at http://www.dol.gov/libraryforms/FormsByNum.asp. However, even though technology for automated collection of this information is currently available this form is initiated by the Government Agency (OWCP), not by the general public and it can require multiple signatures from different private and or public entities and therefore should not be made available for electronic submission.

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

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

6. 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 were no longer entitled to death benefits would receive those benefits, thereby creating overpayments of compensation.

7. There are no special circumstances for the collection of this information.

8. Previously, a Federal Register Notice inviting comment was published on December 7, 2007. No comments were received.

9. No payment or gift is provided to respondents.

10. The information collected by this form is maintained in FECA claim files, which are fully protected under the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1. http://www.usdoj.gov/oip/privstat.htm and http://www.dol.gov/sol/privacy/dol-govt-1.htm

11. This form does not ask questions of a sensitive nature.

12. 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 will take approximately 5 minutes for each respondent to provide the information that is requested. Based on actual usage, it is estimated that 4,850 forms will be used annually. 1/12 or .083 of an hour .083 X 4,850 = 403 hours

Because the wage category of most of the respondents is not known, we have estimated the cost of the burden hours using the National Average Weekly Wage for non-supervisory workers on private non-agriculture payrolls as computed by BLS, or $16.76 per hour.

$16.76 X 403 hrs. = $6,754 respondent cost. http://www.bls.gov/ces/cesbtabs.htm

13. Operating and maintenance costs consist of the price of postage to return the form. The form is a self-mailer and does not require an envelope. $.41 X 4,850 = $1,989.

14. Cost to the Federal government:

Time to review each form - 1/12 = .083 of an hour

Hourly wage of reviewer - $28.73(GS-11/5)

http://www.opm.gov/oca/07tables/html/RUS_h.asp

4,850 X $28.73 X .083 = $11,565 = processing costs

Processing Cost - $11,565

Printing Costs - $ 150

Mailing Costs - $ 1,989

Total - $ 13,704

15. There are currently 4,850 receiving death benefits vs. 5,450 in the prior submission. There is an adjustment of -51 burden hours this submission, the reporting hours in the previous submission was 454 and has change to 403 hours. The operation and maintenance cost has decreased from $2,017 to $1,989 due to an decrease in the number of forms that will be mailed out.

16. The information collected with this form will not be published.

17. No exception to display of the expiration date is sought.

18. There are no exceptions to certification.

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