Notice of Recurrence

Forms and Documents

Document Name	Status
Form CA-2a Notice of Recurrence Form and Instruction	Modified
Supplemental Document 20 cfr 10.104.doc Supplementary Document	2014-01-31
Pay & Leave Salaries & Wages - OPM_gov omb 1240-0009.mht Supplementary Document	2014-01-31
2013 Average weekly wage for non supervisory workers-omb 1240-0009.xls Supplementary Document	2014-01-31
3 Summary of Revisions for CA-2a 1 4-21-2011 final.doc Supplementary Document	2011-04-21
Supporting Statement 1240-0009 2014.doc Supporting Statement A	2014-06-25
omb 1240-0009 supportingn documentation 8101.doc Supplementary Document	2014-01-31

IC Document Collections

IC ID	Document Title	Status
13870	Notice of Recurrence Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0009	ICR Reference No: 201401-1240-001
Status: Historical Active	Previous ICR Reference No: 201101-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Recurrence
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: 08/27/2014
	Date Received in OIRA: 06/25/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2014
Responses	258	0	314
Time Burden (Hours)	129	0	157
Cost Burden (Dollars)	134	0	148

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Abstract: 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.

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Authorizing Statute(s): US Code: 5 USC 8101, et seq 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:
	79 FR 15143	03/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 36099	06/25/2014
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
Notice of Recurrence	CA-2a	Notice of Recurrence

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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	258	314	0	0	-56	0
Annual Time Burden (Hours)	129	157	0	0	-28	0
Annual Cost Burden (Dollars)	134	148	0	0	-14	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 DOL has revised the form to enhance the Privacy Act Statement and make a few formatting changes, those changes are not expected materially to affect the public burden in responding to this information collection. These changes include: Question 8 on the Form CA-2a has revised to comply with current federal law and FECA Bulletin No. 14-01, December 12, 2013. Additionally, the two sentences involving instructions to the employing agency regarding issuance of a CA-16 and return to work were deleted as they are no longer valid. Lastly, an accommodation statement was placed on the form to inform claimants who have mental or physical limitations to contact DFEC for if further assistance is needed in the claims process. Over the last three fiscal years (FY 2011-2013) an average of 5,162 recurrences were submitted, a decrease of 1,111 claims per year (6,273 was the average figure in the previous ICR submission in 2011). In applying the 5% rule described in the discussion in section A.1 of the supporting statement towards the number of claims being submitted by claimants who have left federal employment, the number of claims submitted by this group during this period is 258. This figure represents a reduction of 56 claims since the last OMB submission (5% X 5,162 = 258 (current) versus 314 (5% of 6,273 = 314 (previous submission). The requested annual cost burden in dollars is $134 (.52 x 258), which is a decrease of $14.00 from the previous submission of $148 (.47 x 314 = $148).

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Annual Cost to Federal Government: $5,159

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: 06/25/2014

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