Claim for Continuance of Compensation

Forms and Documents

Document Name	Status
Form CA-12 Claim for Continuance of Compensation Form	Modified
GOVT-1.doc Supplementary Document	2014-02-05
Section 8133 omb 1240-0015.doc Supplementary Document	2014-02-04
2013 Average weekly wage for non supervisory workers-omb 1240-0015.xls Supplementary Document	2014-02-04
Pay & Leave Salaries & Wages - OPM_gov.mht Supplementary Document	2014-02-04
Supporting Statement 1240-0015 2014.doc Supporting Statement A	2014-03-14

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: 201402-1240-001
Status: Historical Active	Previous ICR Reference No: 201011-1240-003
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: 07/14/2014
	Date Received in OIRA: 06/13/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	36 Months From Approved	07/31/2014
Responses	4,083	0	4,570
Time Burden (Hours)	339	0	379
Cost Burden (Dollars)	2,001	0	2,011

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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:
	79 FR 12225	03/04/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 33952	06/13/2014
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
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	4,083	4,570	0	0	-487	0
Annual Time Burden (Hours)	339	379	0	0	-40	0
Annual Cost Burden (Dollars)	2,001	2,011	0	0	-10	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: There are currently 4,083 individuals receiving death benefits vs. 4,570, which were reported in the previous OMB submission, a difference of 487 respondents. The annual IC Time Burden (hours) is 339, which is a decrease of 40 hours based on the previous reporting hours of 379. The operation and maintenance costs associated with this submission is $2001 (a decrease of $10.00 from the previous figures of $2011) due to decreased in respondents. The instructions and questions on the form have been revised to comply with current federal law and FECA Bulletin No. 14-01, December 12, 2013. This change impacts augmented compensation, survivor benefits, death gratuity, schedule awards unpaid at death, and other DFEC administered benefits. In the certification part of the form, two changes were made. The form asks for signature of the claimant which was changed to beneficiary. Where the beneficiary signs by a mark ("X"), the revised form now requires two witnesses. Finally, 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.

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Annual Cost to Federal Government: $15,167

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: 06/13/2014

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