Notice of Recurrence

ICR 200803-1215-003

OMB: 1215-0167

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2008-04-11
Supplementary Document
2008-03-13
Supplementary Document
2008-03-13
IC Document Collections
IC ID
Document
Title
Status
13870 Modified
ICR Details
1215-0167 200803-1215-003
Historical Active 200505-1215-001
DOL/ESA
Notice of Recurrence
Extension without change of a currently approved collection   No
Regular
Approved without change 05/28/2008
Retrieve Notice of Action (NOA) 04/25/2008
  Inventory as of this Action Requested Previously Approved
05/31/2011 36 Months From Approved 07/31/2008
680 0 708
340 0 354
299 0 0

This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.

US Code: 5 USC 8101, et seq Name of Law: Federal Employees' Compensation Act
  
None

Not associated with rulemaking

  72 FR 71699 12/18/2007
73 FR 22432 04/25/2008
No

1
IC Title Form No. Form Name
Notice of Recurrence ca-2a Claim for Recurrence

  Total Approved 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 680 708 0 0 -28 0
Annual Time Burden (Hours) 340 354 0 0 -14 0
Annual Cost Burden (Dollars) 299 0 0 0 299 0
No
No
There is a decrease of 28 in the number of claims being submitted by claimants who have left federal employment, which results in a burden hour reduction of -14.

$10,410
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Carol Adams 904 357-4747 ext. 74105

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
04/25/2008


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