SS 1240-0013 supporting statement revised[1]

SUPPORTING STATEMENT

CLAIM FOR COMPENSATION BY DEPENDENTS INFORMATION REPORTS

OMB NO. 1240-0013 (Formerly 1215-0155)

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

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 5 U.S.C 8110 and 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

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 U.S. C. 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. 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.

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. 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 for adopting this means of collection. Also

describe any consideration of using information technology

to reduce burden.

In accordance with the Government Paperwork Elimination Act GPEA), the Division of Federal Employees’ Compensation seeks to allow individuals and entities that deal with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate. The Forms CA-5, CA-5b, CA-1031 and CA-1074 can be downloaded from the following website:

http://www.dol.gov/owcp/dfec/regs/compliance/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; OWCP 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. 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 2

above.

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. If the collection information impacts small businesses or

other small entities (Item 5 of 014B Form 83-1), describe

any methods used to minimize burden.

This information collection does not have a significant

economic impact on a substantial number of small entities.

6. Describe the consequence of 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

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.

7. Explain any special circumstance.

There are no special circumstances impacting this 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.

A Federal Register Notification inviting public comment (under the former OMB Control No. 1215-0155) was published on January 28, 2010. No comments were received.

9. Explain any decision to provide any payment or gift 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,

regulations or agency policy.

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. The

applicable Privacy Act system of records is DOL/GOV-1 at

website:

http://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.

None of these forms ask questions of a sensitive nature.

12. 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

make special surveys to obtain information on which to base

burden estimates. Consultation with a sample of potential

respondents are desirable. If the burden on respondents is

expected to vary widely because of differences in activity,

size, or complexity, show the range of estimated burden and

explain the reason for the variance. Generally, estimates

should not include burden hours for customary and usual

business practices. Provide estimates of the hour burden of

the collection of information.

The number of responses, number of minutes per response, and total number of hours per form is as follows:

Form/Letter	Time to Complete	Frequency of Response	Number of Respondents	Hours Burden
CA-5	90 min	1	185	278
CA-5b	90 min	1	19	29
CA-1031	20 min	1	146	49
CA-1074	60 min	1	19	19
Student Dependency	30 min	1	925	463
CompDue at Death	30 min	1	64	32
Totals			1358	870

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 the above forms and letters were determined by the average number of responses received for calendar years 2006-through September 2009. 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 870. 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/ces/#tables, or $18.42 per hour (as of June 2009) =$18.42 X 870hours = $16025.

13. Annual Costs to Respondents (capital/start-up & operation

and maintenance).

The only operation and maintenance cost is for postage and

envelope (1358 responses at $.47 per response = $638).

14. Provide estimates of annualized cost to the Federal

government.

Review Costs: The average hourly wage for the reviewer is that of a GS-11/1 $27.03 (Salary Table 2009-RUS, http://opm.gov/oca/09tables/pdf/rus_h.pdf)

Form/Letter	Time to Review	Number of Respondents	Costs
CA-5	30 minutes	185	$2,500.00
CA-5b	30 minutes	19	$257.00
CA-1031	30 minutes	146	$1,973.00
CA-1074	30 minutes	19	$257.00
Student Dependency	9 minutes	925	$3,750.00
CompDue at Death	19.8 minutes	64	571.00
Totals			$9308.00

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 and Envelope Cost: ($0.44-postage) + $0.03 (envelope) x 1358 = $638.

Total Federal Cost: $9308.00 (review costs + estimated printing cost ($15.00) + mailing and envelope costs $638.00) = $9961.00

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

The adjustment in the burden hours is due to having a better accountability of tracking receipt of responses via a computer data base. The previous number of annual respondents of 1880, is being reduced to 1358, which represents a reduction of 522 respondents. The approved number of hours is 1077 and the requested number is 870, a decrease of 207. Due to an increase in postage from $0.42 to $0.47, maintenance and reporting costs increased from the approved amount of $452, to $638, which represents an increase of $186.00.

16. For collections of information whose results will be published, outline plans for tabulation 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 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 OMB Number and expiration date will be displayed.

18. Explain each exception to the certification statement identified in Item "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

There are no exceptions to certification.

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