SUPPORTING STATEMENT
CLAIM FOR COMPENSATION BY DEPENDENTS INFORMATION REPORTS
OMB NO. 1215-0155
1. The forms included in this package are forms used by Federal employees and their dependents to claim benefits, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency. The collection of this information is required by 20 CFR 10.7, 10.105, 10.410, 10.413, 10.417, 10.535, 10.537 (http://www.access.gpo.gov/nara/cfr/waisidx_06/20cfr10_06.html) and 5 USC 8110 (http://nt5.scbbs.com/cgi-bin/om_isapi.dll?clientID=613588&infobase=feca-act.nfo&jump=8110&softpage=PL_frame#JUMPDEST_8110)
Form CA-5 and CA-5b (20 CFR 10.7) are claim forms prescribed in the regulations for use by dependents for claiming compensation for the work related death of a Federal employee. Form CA-5 is used by a surviving spouse or children. Form CA-5b is used by other survivors.
Form CA-1031 is used in disability cases and provides information to determine whether a claimant is actually supporting a dependent (5 USC 8110) and is entitled to additional compensation.
Form CA-1074 is used as a follow-up to Form CA-5b to request clarification of any information that is unclear or incomplete in the CA-5b. Only those questions that are necessary to make a determination of eligibility are asked.
The “Compensation Due at Death" letter is used to request information necessary to distribute compensation due when an employee dies who was receiving or who was entitled to compensation at the time of death for either disability benefits or a schedule award.
The "Student/Dependency" letter is used to obtain information regarding the student status of a dependent. When a child reaches 18 years of age, they are no longer considered an eligible dependent unless they are a full time student or incapable of self-support.
2. Claims examiners for the Office of Workers' Compensation Programs (OWCP) use the information obtained by the forms and letters described to determine entitlement to benefits under the Federal Employees' Compensation Act. These forms are studied, dependents are verified, and benefit payments are initiated, continued, adjusted, or terminated accordingly. Without the information requested by the forms, determinations regarding entitlement to benefits could not be made, and OWCP could not ensure that compensation was paid to the correct individuals at the correct rate. Failure to verify dependent information could result in significant overpayment, which would be very difficult to recover.
3. In accordance with the Government Paperwork Elimination Act (GPEA), DFEC recognizes the requirement that all OMB forms when practicable be electronically interactive by October 2003. The Employment Standards Administration’s (ESA) Division of Information Technology and Service (DITMS) are currently studying a method of providing electronic interactivity to all of DFEC forms. By using technology currently available, ESA will offer these forms to the public in the same manner that other DFEC forms are made available.
The Forms CA-5, CA-5b, CA-1031 and CA-1074 can be downloaded from the ESA Internet site http://www.dol.gov/esa/regs/compliance/owcp/forms.htm. For numerous reasons, including but not limited to the low volume of usage and cost, and the fact that Forms CA-1031 and CA-1074 are initiated by OWCP, not by the general public, these forms are not electronically interactive; ESA contends that this level of automation is not practicable for these forms. The "Compensation Due at Death" and "Student/Dependency" letters are initiated solely by OWCP after the Office performs computer matches on an ongoing basis to assist in determining whether benefits are being paid appropriately.
4. The information requested on these forms is not duplicative of any information available elsewhere. The beneficiary is the only source of the required information.
5. This information collection does not have a significant economic impact on a substantial number of small entities.
6. Forms CA-5, CA-5b, CA-1074 and Letter "Compensation Due at Death" are required only once, to establish dependent/eligibility status. Without the information requested, no determination could be made regarding the payment of benefits.
Letter of "Student/Dependency" is required once to establish entitlement. In cases where student status is established, it is required twice during the school year to verify that the dependent continues to qualify for dependent status. The requests coincide with the school year semesters as the student status has to be verified each semester.
The CA-1031 is sent only as needed, but no more often than once a year. If these requests were sent less often, overpayments of compensation could occur which would be costly to recapture and impose a burden on the beneficiary.
There are no special circumstances impacting this collection.
8. A Federal Register Notification inviting public comment was published on November 14, 2006. No comments were received.
9. No payment or gifts are provided to respondents.
10. All information contained in FECA claim files is fully protected under the Privacy Act. All forms used for initiating a compensation claim contain a statement advising the claimant of the provisions of the Privacy Act (http://www.usdoj.gov/foia/privstat.htm). The applicable Privacy Act system of records is DOL/GOV-1 (http://www.dol.gov/sol/privacy/dol-govt-1.htm).
11. None of these forms ask questions of a sensitive nature.
12. The number of responses, number of minutes per response, and total number of hours per form is as follows:
Form/Letter # Responses Mins. Per form Total Hours
CA-5 150 90 225
CA-5b 20 90 30
CA-1031 150 15 37
CA-1074 10 60 10
Student/Dependency 1,050 30 525
Comp Due at Death 500 30 250
TOTAL 1880 1077
The burden for most of these forms was determined by estimating the total number of these forms received during a year. The number of respondents for Forms CA-5 and CA-5b was determined by the number of death claims anticipated during a 1 year period. The time required to complete each form is based upon reviewing each form and estimating the time necessary to obtain the required information and complete the form, both by the claimant or beneficiary, and the person providing certification of the information.
The combined burden hours have been calculated to be 1,077. Because the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage for production or nonsupervisory workers on private nonagriculture payrolls as computed by BLS (http://www.bls.gov/news.release/empsit.t16.htm), or $12.70 per hour. $12.70 X 1077 hours = $13,678.
13. The only operation and maintenance cost is for postage and envelope (1,077 responses at $.42 per response = $452).
14. Federal Cost Estimate:
Printing Cost: The printing cost of the CA-5 and CA-5b is approximately $7.50 per hundred, or a total of $15 per year. All other forms are generated by the word processing program in the automated system in each district office.
Mailing Cost: 1,880 forms X $.42 postage and envelope = $790.
Processing Cost: hourly wage of GS-11/1 $24.90 (Salary Table 2006-RUS, http://opm.gov/oca/06tables/pdf/rus_h.pdf)
CA-5 .5 X 150 = 75 hours
CA-5b .5 X 20 = 10
CA-1031 .5 X 150 = 75
CA-1074 .5 X 10 = 5
Student/Dependency .15 X 1,050 = 158
CompDue at Death .33 X 500 = 165
Total 488 hours
488 Hours X $24.90/Hr. = $12,151
Total Cost: Printing 15
Mailing 790
Salary 12,151
Total $12,956
15. The burden hours for this collection have not changed. The operating and maintenance costs are adjusted based upon rising cost.
Data collected with these forms will not be published.
The OMB Number and expiration date will be displayed.
There are no exceptions to certification.
| File Type | application/msword |
| File Title | Supplemental Statement |
| Author | Unknown |
| Last Modified By | US Department of Labor |
| File Modified | 2006-11-14 |
| File Created | 2006-11-14 |