Claim for Continuance of Compensation

Forms and Documents

Document Name	Status
Form CA-12 Claim for Continuance of Compensation Form	Modified
3. SUMMARY OF REVISIONS TO CA-12.doc Supplementary Document	2011-02-18
10. Salary Table 2010-RUS.mht Supplementary Document	2010-11-05
9. Average hours and earnings of production and nonsupervisory employees.txt Supplementary Document	2010-11-05
7. 5 USC 8133 FECA[1].doc Supplementary Document	2010-11-05
6. 20 CFR 10.414[1].doc Supplementary Document	2010-11-05
8. DOL_GOVT-1[1].doc Supplementary Document	2010-11-05
Supporting_Statement_1240-0015 final version 4-27-2011.doc Supporting Statement A	2011-04-27

IC Document Collections

IC ID	Document Title	Status
13838	Claim for Continuance of Compensation Form	Modified

ICR Details

OMB Control No: 1240-0015	ICR Reference No: 201011-1240-003
Status: Historical Active	Previous ICR Reference No: 201003-1240-015
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Continuance of Compensation
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/01/2011
	Date Received in OIRA: 05/03/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved	05/31/2011
Responses	4,570	0	4,850
Time Burden (Hours)	379	0	403
Cost Burden (Dollars)	2,011	0	1,988

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Abstract: This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.

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Authorizing Statute(s): US Code: 5 USC 8133 Name of Law: Federal Employees' Compensation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 82075	12/29/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 24913	05/03/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Continuance of Compensation	CA-12	Claim for Continuance of Compensation Under the Federal Employees' Compensation Act

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ICR Summary of Burden

	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	4,570	4,850	0	0	-280	0
Annual Time Burden (Hours)	379	403	0	0	-24	0
Annual Cost Burden (Dollars)	2,011	1,988	0	0	23	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: While the DOL has revised the form to collect Social Security Numbers and make a few formatting changes, those changes do not materially to affect the public burden estimates for responding to this information collection. There are currently 4,570 individuals receiving death benefits vs. 4,850 in the prior submission. There is an adjustment of -24 burden hours this submission, the reporting hours in the previous submission was 403, and has changed to 379 hours. The operation and maintenance cost has increased ($23.00) from $1988 to $2011 due to adjustment in postage cost from .41 to .44 cents to return completed forms. The adjustments described above are attributed to enhanced computer capabilities to track filing of these types of claims.

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Annual Cost to Federal Government: $14,667

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 05/03/2011

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