SUPPORTING STATEMENT
CLAIM FOR COMPENSATION BY DEPENDENTS INFORMATION REPORTS
OMB NO1240-0013
Justification:
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 used to request information for entitlement to claim benefits under the Federal Employees’ Compensation from federal employees/their dependents/ survivors, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee, and to show dependency. The following Codes of Federal Regulations for this OMB apply to Claims for Compensation under the Federal Employees’ Compensation Act, as amended: 20 CFR 10.7, 10.105, 10.410, 10.413, 10.417, 10.535, 10.537. See 5 U.S.C. Sections 8110, 8124, 8145, and 8149.
https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm
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 from 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 (DFEC) allows 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.
However, to improve upon the capabilities for the public to submit DFEC documents, OWCP has developed an alternative to mailing of documents. This application, known as The Employee Compensation Operations and Management Portal (ECOMP) is internet based, and allows the users the ability to submit these forms electronically into their respective case record. This application is available to the claimant, employing agency, and the medical provider. There is no cost to the claimant.
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, 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 used by OWCP to determine a claimant’s entitlement to augmented compensation. At least once each year, OWCP may ask an employee who receives compensation based on the student status of a child to provide proof of continuing entitlement to such compensation, including certification of school enrollment.
Also, at least once each year, OWCP will ask an employee who receives compensation based on a child's physical or mental inability to support himself or herself, to submit a medical report verifying that the child's medical condition persists and that it continues to preclude self- support.
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 was published on March 8, 2016 (81 FR 12129). No public 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 (67 FR 16826)
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.
Forms CA-5, CA-5b, CA-1074, and the Student Dependency Letters include a Privacy Act statement that defines when and for what purposes may be disclosed, The Privacy Act Statements on the forms will read as follows:
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
We are authorized to request a taxpayer identification number (TIN) or Social Security Number (SSN) under the Debt Collection Improvement Act of 1996, Title 31 U.S.C. amended section 7701(c) (1), which mandates us to require regulated entities and persons who are doing business with a Federal agency to furnish a TIN or SSN. The SSN or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts, carried on by the Federal government and for other purposes required or authorized by law.
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 is 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 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 Forms CA-5 and CA-5b was determined by the number of death claims anticipated during a 1-year period.
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 964.
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 non-agriculture payrolls as computed by BLS is $25.24 per hour—for a total respondent cost burden of $24,332.
Estimated Annualized Respondent Hour and Cost Burdens
Form/Letter |
Number of Respondents |
Number of Responses per Respondents
|
Total Number of Responses |
Average Burden per Response (in Hours) |
Total Burden Hours |
Hourly Wage Rate* |
Total Burden Costs |
CA-5 |
129 |
1 |
129 |
90/60 |
194 |
25.24 |
4,897 |
CA-5b |
7 |
1 |
7 |
90/60 |
11 |
25.24 |
278 |
CA-1031 |
83 |
1 |
83 |
20/60 |
28 |
25.24 |
707 |
CA-1074 |
5 |
1 |
5 |
1 |
5 |
25.24 |
126 |
Student Dependency Letter |
1,111 |
1 |
1,111 |
30/60 |
556 |
25.24 |
14,033 |
Comp Due at Death Letter |
340 |
1 |
340 |
30/60 |
170 |
25.24 |
4,291 |
Totals |
|
|
|
|
964 |
|
$24,332 |
*See website:
http://www.bls.gov/opub/ee/2015/ces/summarytable_201512.pdf
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
The only operation and maintenance cost is for postage and envelope (1,675 responses at $.52 per response = $ 871.00.
Total claimant costs [$0.49 (postage) + $0.03 (envelopes)] x 1,675(forms) =$871.00
14. Provide estimates of annualized cost to the Federal government.
Review Costs: The average hourly wage for the reviewer is that of a GS-12/6 $39.70.
See website: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2016/RUS_h.pdf
Form/Letter |
Time to Review |
Number of Respondents |
Costs |
CA-5 |
30 minutes |
129 |
$2,561.00 |
CA-5b |
30 minutes |
7 |
139.00 |
CA-1031 |
30 minutes |
83 |
1,648.00 |
CA-1074 |
30 minutes |
5 |
99.00 |
Student Dependency |
9 minutes |
1,111 |
6,616.00 |
CompDue at Death |
19.8 minutes |
340 |
4,454.00 |
Totals |
|
1,675 |
15,517.00 |
Federal Cost Estimate:
Printing Cost: Due to the small number of claims received for the CA-5 and CA-5b, there are no plans to print the form in bulk for distribution. All other forms are generated by the word processing program in the automated system in each district office.
Mailing and Envelope Cost: $0.49 (postage) + $0.03 (envelope) x 1,675 = $871.
The total Federal cost for mailing and processing of these documents is $16,388 ($15,517.00 + $871.00)
15. Explain the reasons for any program changes or adjustments reported.
The estimated number of annual respondents (1,675) is a decrease of 1,245 from the previous request of 2,920. The estimate in burden hours (964) is a decrease of (607) from the previously approved 1,571. Additionally, the estimated cost burden of $871 is $560 less than the previously requested of $1,431.
For this adjustment, much of the decrease associated with burden costs and hours is attributed to a significant reduction of respondents in the use of the CA-1074, the Student Dependency and Compensation Due at Death Letters.
To determine the estimated number of respondents, DFEC used a computer generated listing to provide numbers based on documents that are imaged in the claimant’s case file based on category/subject/author date.
However, initial numbers, particularly for the Compensation Due at Death for example, were skewed. Upon closer review of the imaged record, it was found that the category/subject of this letter varied in many instances, which resulted in DFEC needing to actually review the case records to determine a more accurate estimate for this letter. Any document that is imaged into a claimant’s case file is viewed using a category/subject/author date, etc.
Summaries of the revisions to the forms/letters are noted below. The revisions do not affect the burden hours:
CA-5:
Page 1.
Revised Title of Form to “Claim for Compensation by Surviving Spouse, and/or Children” versus “Claim for Compensation by Widow, Widower, and/or Children”.
Between items 7 and 8. Changed references to husband/wife to “spouse”
Between items 24 and 26, revised certification statement as follows:
“I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits”
Placed the following Accommodation language on the bottom of the form.
“If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP. See Instructions for additional details.”
Page 2:
Item 9, added “or employment related disease” after “injury”.
Item 11. Included physician in the “name and address”
Item 12 revised certification statement of physician as follows:
“I certify that the statements in response to the questions asked above are true, complete, and correct to the best of my knowledge. Further, I understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may subject me to criminal prosecution. “
Pages 3 and 4(Instructions).
Changed title of Instructions to, “Instructions for Completing Form CA-5, Claim for Compensation by Surviving Spouse and/or Children.”
Changed various references to “widow/widower” to “ surviving spouse”
Revised accommodation statement as follows:
Request for Accommodations or Auxiliary Aids and Services.
“If you have a disability, Federal law gives you the right to receive help from the OWCP/DFEC in the form of communication assistance, accommodation(s) and/or modification(s) to aid you in the FECA claims process. For example, we will provide you with the copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or your OWCP claims examiner to ask about this assistance.”
Page 4.
Changed Title page to “Death Benefits for Surviving Spouse and/or Children under the Federal Employees’ Compensation Act (FECA)”.
Revised 1st bullet on Surviving spouse to the following:
“To qualify for benefits, a surviving spouse must have been living with the employee or separated for reasonable cause prior to the time of death. Payments continue for life or until remarriage before age 55. Upon remarriage before age 55, a surviving spouse will receive a lump sum equal to 24 times his or her monthly compensation. If the remarriage occurs at age 55 or later, no lump sum is paid. Instead, payments continue for life.”
Page 5.
Removed reference to “For Sale by the Superintendent of Documents’U.S. Government Printing Office….”
Removed Accommodation Statement and moved to page 3 with revisions as noted above.
CA-5b:
Page 1:
Between items 20 and 21. Changed reference to husband/wife, to “spouse”, i.e., “Information about spouse”.
Item 25. Changed husband/wife to “spouse”
Between items 34 and 35, revised certification statement as follows:
“I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits”
Placed the following Accommodation language on the bottom of the form.
“If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP. See Instructions for additional details. ”
Page 2.
Item 9, added “or employment related disease” after injury.
Item 11. Included physician in the “name and address”
Between items 11 and 12, revised certification statement of physician as follows:
“I certify that the statements in response to the questions asked above are true, complete, and correct to the best of my knowledge. Further, I understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may subject me to criminal prosecution. “
Page 3, Instructions.
Removed from page 5 and revised accommodation language as follows to the top of the page:
Request for Accommodations or Auxiliary Aids and Services
“If you have a disability, Federal law gives you the right to receive help from the OWCP/DFEC in the form of communication assistance, accommodation(s) and/or modification(s) to aid you in the FECA claims process. For example, we will provide you with the copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or your OWCP claims examiner to ask about this assistance. “
4th bullet, Under How to Complete Claim, Line 4: Revised to dependents “spouse” vs "husband or wife".
Page 4.
6th bullet: Under Payment Priorities, Line 2,changed to, "the surviving spouse" vs "widow or widower"
Line 4, change to “the surviving spouse” vs “widow or widower.
Page 5.
Removed reference to “For Sale by the Superintendent of Documents/Government Printing Office...”
CA-1074:
Page 1.
Added space for the placement of a “File Number”on the letter.
Revised accommodation on bottom of form to the following:
“If you have a disability and are in need of communication assistance such as alternate formats or sign language interpretation), accommodation (s) and/or modification(s), please contact OWCP.
Page 3.
Revised certification statement as follows:
“I certify that the information provided in the attached questionnaire is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.”
Page 4.
Added the following Privacy Act Statement.
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, to verify earnings without further written authorization, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
CA-1031:
Page 1.
Question 1, first line: Changed references to “wife/husband” to “spouse”
Revised accommodation on bottom of form to the following:
“If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodation(s) and/or modification(s), please contact OWCP.”
Page 2.
Revised certification statement as follows:
”I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.”
Compensation Due at Death
Page 1.
1st paragraph, 3rd line after “death” Added the following phrase, “because the claimant had claimed disability compensation prior to death.”
Revised accommodation on bottom of form to the following:
“If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodation(s) and/or modification(s), please contact OWCP.”
Page 2.
Revised certification statement as follows:
“I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.”
Student Dependency
Page 1.
Revised accommodation on bottom of form to the following:
“If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodation(s) and/or modification(s), please contact OWCP.”
Page 3.
Added the following Privacy Act Statement.
“In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, to verify earnings without further written authorization, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Page 4.
Revised the certification statement to the following:
”I certify that the information provided on this questionnaire is true and accurate to the best of my knowledge and belief. Any information left blank on this form has been done intentionally and indicates I had no information to provide for that question. I understand that any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.”
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 ROCIS.
There are no exceptions to certification.
B. Collections of Information Employing Statistical Methods
Statistical methods are not used in these collections of information.
| File Type | application/msword |
| File Title | Supplemental Statement |
| Author | Sharpless, Marcus J - OWCP |
| Last Modified By | Ferguson, Yoon - OWCP |
| File Modified | 2016-08-18 |
| File Created | 2016-08-18 |