Statement of Recovery Forms

Forms and Documents

Document Name	Status
Form ca-1122 Statement of Recovery Form and Instruction	Unchanged
Form ca-1108 Statement of Recovery Forms Form and Instruction	Modified
Notice to Reviewer CA-1108 nonmaterial change(20160912).docx Justification for No Material/Nonsubstantive Change	2016-09-12
DOL_GOVT-1 omb 1240-0001 2015.doc Supplementary Document	2015-04-17
2015 opm salary table rus omb 1240-0012.pdf Supplementary Document	2015-04-17
BLS Occupational Employment and Wages, 2014.docx Supplementary Document	2015-04-17
BLS National Compensation Survey-2011.pdf Supplementary Document	2015-04-17
Supporting Statement 1240-0001 2015.docx Supporting Statement A	2015-08-05

IC Document Collections

IC ID	Document Title	Status
188783	Statement of Recovery Form and Instruction	Unchanged
13938	Statement of Recovery Forms Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0001	ICR Reference No: 201609-1240-002
Status: Historical Active	Previous ICR Reference No: 201504-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Statement of Recovery Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/13/2016
	Date Received in OIRA: 09/12/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2018	11/30/2018	11/30/2018
Responses	842	0	842
Time Burden (Hours)	419	0	419
Cost Burden (Dollars)	219	0	219

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Abstract: These forms are used to obtain information about amounts received as the result of final judgments in litigation, or a settlement of the litigation, brought against a third party who is liable for damages due to a Federal employee comprehensive work-related injury.

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Authorizing Statute(s): US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8131 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:
	80 FR 26955	05/11/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 47527	08/07/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Statement of Recovery	ca-1122	Statement of Recovery
Statement of Recovery Forms	ca-1108	Statement of Recovery

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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	842	842	0	0	0	0
Annual Time Burden (Hours)	419	419	0	0	0	0
Annual Cost Burden (Dollars)	219	219	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:

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Annual Cost to Federal Government: $12,032

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: 09/12/2016

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