1240-0018 Supporting Statement 2016

Claim for Reimbursement-Assisted Reemployment, CA-2231

1240-0018

May 2016

SUPPORTING STATEMENT

OMB NO. 1240-0018

FORM CA-2231

CLAIM FOR REIMBURSEMENT-ASSISTED REEMPLOYMENT

1. Justification

1. 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 Office of Workers’ Compensation Programs (OWCP) administers the Federal Employees’ Compensation Act (FECA) under 5 U.S.C. 8101 et seq. Section 8104(a) of the FECA provides vocational rehabilitation services to eligible injured workers to facilitate their return to work. The costs of providing these vocational rehabilitation services are paid from the Employees’ Compensation Fund. Annual appropriations language (currently in Public Law 114-113), provides OWCP with legal authority to use amounts from the Fund to reimburse private sector employers for a portion of the salary of reemployed FECA claimants hired through OWCP’s assisted reemployment program.

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.

Information collected on Form CA-2231 provides OWCP with the necessary remittance information for the employer, documents the hours of work, certifies the payment of wages to the claimant for which reimbursement is sought, and summarizes the nature and costs of the wage reimbursement program for a prompt decision by OWCP.

Failure to collect this information would prevent timely and accurate reimbursement to employers, hinder the documentation of disbursements from the Fund, and obstruct implementation of the assisted reemployment program.

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 United States (US) Department of Labor (DOL) recognizes the requirement that all Office of Management and Budget (OMB) Forms be made electronically interactive. CA-2231 is currently posted on the internet at https://www.dol.gov/owcp/regs/compliance/ca-2231.pdf for downloading by private sector employers. The form may be electronically filled.

Due to the low usage of this form (an average of 128 annually), we believe it sufficient that it be electronically filled only. The form can be downloaded, printed, and submitted by mail, or by secure fax.

The employer should fill out applicable items on the digital version of the form on-line found on the DOL website. The form must be printed out in order to obtain the certifications of the employer and the injured worker. The form may then be mailed, faxed or uploaded by the Rehabilitation Counselor directly to the OWCP’s online case management system for further processing by the Rehabilitation Specialist.

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 collected on this form is not duplicative of any information available elsewhere. The respondent is the only source of the data needed to process the reimbursement request.

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.

 

Please refer to nos. 1 and 2 above. The information collected from private sector employers is the minimum needed to evaluate whether a reimbursement request meets the requirements of OWCP’s assisted reemployment program. Reimbursement requests cannot be processed by OWCP without the information collected.

7. Explain any special circumstance required in the conduct of this information collection.

 

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.

 

The last Federal Register Notice inviting comment was published on March 23, 2016 (81 FR 15572). Comments were not received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

 

No payment or gift is 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 collected by and submitted with Form CA-2231 is protected under the Privacy Act in the system of records known as DOL/GOVT-1 (http://www.dol.gov/sol/privacy/dol-govt-1.htm)

The form includes a Privacy Act statement that defines when and for what purposes may be disclosed, namely:

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.

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.

 

The form requests the respondent to supply a taxpayer identification number (TIN), which falls under the personally identifiable information. As noted above, the TIN 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. Provide estimates of the hour burden of the collection of information. The statement should:

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.

According to the records maintained by OWCP, there are approximately 32 respondents involved in the assisted reemployment program at any one time. During the past three years, approximately 388 Forms CA-2231 have been processed, which is a yearly average of 128. This form is submitted quarterly from each employer requesting partial wage reimbursement. It is estimated that it takes ½ hour for a respondent to collect the information from its payroll records, fill in Form CA-2231, and return it to OWCP. The total annual hour burden, therefore, is estimated to be 64 hours (128 responses x 0.5 hours/response).

Using the current median hourly wage for payroll and timekeeping clerks (reported by the Bureau of Labor Statistics, http://www.bls.gov/oes/current/oes433051.htm of $19.71 per hour, the respondent annualized cost estimate for this collection is $1,261.44. ($19.71 X 64), or

$1,161.00, rounded down.

13. Annual Costs to Respondents (capital/start-up & operation and maintenance). 

There is no capital/startup or ongoing operation/maintenance costs associated with this information collection. Operation and maintenance costs consist solely of mailing costs. With 128 mailed responses, the estimated annual operation and maintenance costs is $66.56 (128 X $0.52 (based on $0.49 for postage + $0.03 for an envelope)), or $67.00, rounded up.

14. Provide estimates of annualized cost to the Federal government.

 

The estimated costs to the Federal government of collecting the information on Form CA-2231 are set out below:

Printing costs: Due to the small number of respondents that use Form CA-2231 to request reimbursement from OWCP, there are no plans to print the form in bulk for distribution.

Mailing/Developmental costs: Private sector employers who wish to request reimbursement under the assisted reemployment program can download Form CA-2231 directly from the internet and for that reason; no mailing costs for the form are incurred. There are also no developmental costs associated with this collection information.

Processing/Reviewing costs: Reimbursement requests are evaluated by OWCP Rehabilitation Specialists employed at the GS-12, step 6 levels. It takes them an average of 10 minutes to review the form. Based on the estimated number of responses, the total time spent reviewing all 128 responses to Form CA-2231 is 1,280 minutes or 21.33 hours or 21 hours (rounded down)(1,280 minutes divided by 60 minutes/hour) annually.

It costs $834 to process 128 reimbursement requests ($39.70 per hour) at the GS 12, step 6 level x 21 hours = $833.70 or 834.00, rounded up. Reference: Salary Table 2016-RUS https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/16Tables/html/RUS_h.aspx

15. Explain the reasons for any program changes or adjustments.

The adjustments in the burden hours are due to a decrease in the number of participating employers. The previous approved number of annual respondents (42) decreased to approximately (32), which represents a decrease of 10 respondents. The previously approved number of burden hours was 84; the requested number of hours is 64, which is a decrease of 20 hours. In addition, postage and envelope costs, the maintenance and reporting costs is now $67.00, which is a reduction of $15.00, from the previous amount of $82.00.

A summary of revisions to the form is noted below:

• Instructions

Changed the reference to the Public Law from 196.554 to Public Law 113.235. Added the following accommodation language to the end of the Instructions.

“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 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.”

• Item 5, replaced “Bill Payment Number” to “Employer’s Assigned Bill Payment/ Provider Number”.

• Items 6, 7, and 8. Replaced references to “claimant” with “employee”.

• Item 9. Changed “Date Employment Began” to “Date of AR Agreement”.

• Item 10. Changed “Dates and Hours Worked” to “Work Date Ranged Claimed and Total work Hours for Reimbursement”.

• Item 10. Changed “Hours” to “Total Hours”.

• Item 12. Changed “Total Amount Earned” to ”Total Gross Amount Earned”.

• Revised and Expanded the Certification Statement

From: “I certify that the information provided on this form is true and correct to the best of my knowledge.”

To: “I certify that the statements in response to the information requested above (including that the employee actually worked the dates and total hours claimed on this form) are true, complete and correct to the best of my knowledge. Further, I certify that the employee named above is not the owner of the business and is not related to the employer. 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 and civil remedies.“

• Item 14. Added a line under the supervisor’s signature for Supervisor’s Printed Name.

• Revised Privacy Act Statement by including the following statement at the end of the statement.

“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.”

• Revised the Accommodation Statement on the bottom of page 2 to the following

From: “If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims examiner for information about the kinds of help available such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications.”

To: “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 Form instructions for Requests for Accommodations or Auxiliary Aids and Services.”

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.

 

There are no plans to publish any data collected by the CA-2231.

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 agency plans to display the expiration date for OMB approval of the information collection on all instruments.

18. Explain each exception to the certification statement in ROCIS.

This request is in compliance with 5 CFR 1320.9.

2. Collections of Information Employing Statistical Methods:

Statistical methods are not used in these collections of information.

7