Notice of Recurrence

Forms and Documents

Document Name	Status
Form CA-2a Notice of Recurrence Form and Instruction	Modified
5 usc 8101 for 2017 omb 1240-0009.doc Supplementary Document	2017-03-17
Privacy Act System of Records DOL GOVT-1.doc Supplementary Document	2017-03-17
Salary Table 2017-RUS.pdf Supplementary Document	2017-03-17
Current Employment Statistics- CES (National)Average hourly and weekly earnings of production and nonsupervisory employees on private nonfarm payrolls by industry sector, seasonally.htm Supplementary Document	2017-03-17
Supplemental Document 20 cfr 10.104 for omb 1240-0009 2017 mjs.doc Supplementary Document	2017-03-17
Supporting Statement 1240-0009 2017.doc Supporting Statement A	2017-08-31

IC Document Collections

IC ID	Document Title	Status
13870	Notice of Recurrence Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0009	ICR Reference No: 201703-1240-006
Status: Active	Previous ICR Reference No: 201401-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Recurrence
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: 11/03/2017
	Date Received in OIRA: 08/31/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	36 Months From Approved	11/30/2017
Responses	289	0	258
Time Burden (Hours)	145	0	129
Cost Burden (Dollars)	150	0	134

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Abstract: This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.

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Authorizing Statute(s): US Code: 5 USC 8101, et seq 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:
	82 FR 23613	05/23/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 41306	08/31/2017
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
Notice of Recurrence	CA-2a	Notice of Recurrence

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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	289	258	0	0	31	0
Annual Time Burden (Hours)	145	129	0	0	16	0
Annual Cost Burden (Dollars)	150	134	0	0	16	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: The adjustment for this submission is due to an increase in the number of claims since the last approval. Over the last three calendar (CY2014-2016) an average of 5,770 recurrences were submitted, an increase of 608 claims per year (5,162 was the average figure in the previous ICR submission in 2014). In applying the 5% rule described in the discussion in section A.1 above towards the number of claims being submitted by claimants who have left federal employment, the number of claims submitted by this group during this period is 289 (5% x 5,770). This figure represents an increase of 31 claims since the last OMB submission, 258 (5% of 5,162 ) The requested annual cost burden in dollars is $150 (.52 x 289), which is an increase of $16.00 from the previous submission of $134 (.52 x 258).

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Annual Cost to Federal Government: $5,313

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 08/31/2017

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