Statement of Recovery Forms

ICR 200811-1215-005

OMB: 1215-0200

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
New
Form and Instruction
Modified
Supporting Statement A
2009-05-04
Supplementary Document
2009-04-14
IC Document Collections
ICR Details
1215-0200 200811-1215-005
Historical Active 200604-1215-003
DOL/ESA
Statement of Recovery Forms
Extension without change of a currently approved collection   No
Regular
Approved without change 06/15/2009
Retrieve Notice of Action (NOA) 05/18/2009
  Inventory as of this Action Requested Previously Approved
06/30/2012 36 Months From Approved 06/30/2009
3,000 0 3,200
1,425 0 1,520
1,350 0 1,000

These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.

US Code: 5 USC 8131 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
  
None

Not associated with rulemaking

  73 FR 79194 12/24/2008
74 FR 23207 05/18/2009
No

2
IC Title Form No. Form Name
Claim for Reimbursement-Assisted Reemployment ca-1108 Statement of Recovery
Statement of Recovery ca-1122 Statement of Recovery

  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 3,000 3,200 0 0 -200 0
Annual Time Burden (Hours) 1,425 1,520 0 0 -95 0
Annual Cost Burden (Dollars) 1,350 1,000 0 0 350 0
No
No
The adjustments in the burden hours are due to a decrease in the number of third party claims. The previous approved number of annual responses, 3200, is being reduced to 3,000, which represents a reduction of 200 respondents. The approved number of hours is 1520 and the requested number of hours is 1425,a decrease of 95. In addition, due to an increase in postage, the maintenance and reporting costs have increased from $1,000 to $1,350, which is an increase of $350.00.

$43,185
No
No
Uncollected
Uncollected
No
Uncollected
Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov

  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.
05/18/2009


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