Rehabilitation Maintenance Certificate

Forms and Documents

Document Name	Status
Form OWCP-17 Rehabilitation Maintenance Certificate Form	Modified
2015 opm salary table rus omb 1240-0012.pdf Supplementary Document	2015-03-31
Privacy Act Systems - DOLESA-15.docx Supplementary Document	2015-03-26
DOL GOVT-1.docx Supplementary Document	2015-03-26
Supporting Statement 1240-0012 (OWCP-17) Revised per public comments.docx Supporting Statement A	2015-09-30

IC Document Collections

IC ID	Document Title	Status
43809	Rehabilitation Maintenance Certificate Form	Modified

ICR Details

OMB Control No: 1240-0012	ICR Reference No: 201503-1240-001
Status: Historical Active	Previous ICR Reference No: 201112-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Rehabilitation Maintenance Certificate
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/25/2015
	Date Received in OIRA: 07/23/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2018	36 Months From Approved	11/30/2015
Responses	3,752	0	5,022
Time Burden (Hours)	625	0	837
Cost Burden (Dollars)	0	0	0

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Abstract: Form OWCP-17 serves as a bill submitted by the program participant or OWCP, requesting reimbursement of expenses incurred due to participation in an approved rehabilitation effort for the preceding four-week period of fraction thereof.

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Authorizing Statute(s): US Code: 5 USC 8111 Name of Law: Federal Employees’ Compensation Act
   US Code: 5 USC 8121 Name of Law: Federal Employees’ Compensation Act
   US Code: 33 USC 939 Name of Law: Longshore and Harbor Workers’ Compensation Act
   US Code: 33 USC 908(g) Name of Law: Longshore and Harbor Workers’ 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:
	80 FR 23823	04/29/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 43795	07/23/2015
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
Rehabilitation Maintenance Certificate	OWCP-17	Rehabilitation Maintenance Certificate

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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	3,752	5,022	0	0	-1,270	0
Annual Time Burden (Hours)	625	837	0	0	-212	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: Since the last clearance three years ago, the responses from the respondents decreased from 5,022 to 3,752, which is an adjustment of 1,270 responses. Accordingly, the burden hours decreased from 837 to 625, an adjustment of 212 hours. Summary of revisions to this form includes the following: Several minor changes were made to the form to enhance record-keeping and ease of use as well as to reflect current administrative practices. The space for Injured Worker address was moved from mid-page to the top of the page under the Injured Worker's name for organizational purposes. A "Weekly Training Schedule" section was added to further document the Injured Workers training or educational schedule and to assist with proper payment of maintenance funds. Finally, under "Please Read Carefully," instructions were adjusted to reflect the agency's transition to use of forms in digital format, rather than carbon copies, as well as to more accurately reflect the current administrative practice of Rehabilitation Counselors, rather than Specialists, completing the initial form review. These adjustments will not change the overall administrative function of the form and will not increase user burden.

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Annual Cost to Federal Government: $92,082

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: 07/23/2015

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