RI30-010_OMBSupportingStmt_2018_05_30

RI30-010_OMBSupportingStmt_2018_05_30.docx

Disabled Dependent Questionnaire

OMB: 3206-0179

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OMB SUPPORTING STATEMENT


RI 30-10 Disabled Dependent Questionnaire


  1. Justification


  1. Title 5, U. S. Code, Sections 8341(a)(4)(B) and 8441(4)(B) provide survivor benefits for unmarried, dependent children, regardless of age, who are incapable of self-support because of mental or physical disability incurred before age 18. Section 8901(5)(B), which defines the family members who are eligible for health benefits coverage, includes any unmarried, dependent children, regardless of age, who are incapable of self-support because of mental or physical disability which existed before age 22. RI 30-10 is designed to collect information about the disabled child’s ability to earn a living and to obtain medical facts about the disability.


  1. The information collected is used by the Office of Personnel Management (OPM) to determine whether to pay benefits and include the individual as a family member for health benefits coverage. The person applying is asked about the disabled person’s wage-earning capability, and the attending physician is asked to describe the disability and give other information about the disability and its effect on the person’s ability to make a living. If the information is not collected, OPM cannot determine eligibility or pay benefits, as required by law. The Privacy Act Statement (PAS) has been revised due to a general systematic review by our Chief Privacy Officer for all OPM PAS.


  1. The information collected is detailed and can only be obtained from the respondents. New methods of information technology would do little to reduce the burden on the respondents; they must sign the questionnaire and take it to their physician. However, this form is available on our website in a pdf fillable format and meets our GPEA requirements.


  1. The questionnaires are filed individually because there is no other way to obtain this information. Duplication is minimized.


  1.  This information collection request has no impact on small businesses and organizations.


  1. This information collection is performed as needed to pay benefits or enroll eligible persons. Less frequent collection would delay the payment of survivor annuities or health benefits enrollment provided by law.


  1. There are no special circumstances involved in the collection of this information.


  1. A notice of proposed information collection was published in the Federal Register on May 5, 2017, giving persons outside the agency an opportunity to comment on the form. No comments were received.


  1. No gifts or payments of any kind have been provided to any individuals who are connected to this collection.


  1. This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses for disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008).



  1. The information collection does not include questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. However, RI 30-10 does collect information regarding the disabled child’s medical condition. The information is needed so that OPM can determine whether the child is disabled within the meaning of the law. The respondent is aware that OPM needs the medical documentation and assists in the transaction by taking the RI 30-10 to the child’s physician to obtain the required medical documentation.


12. Approximately 2,500 Disabled Dependent Questionnaires will be processed each year.
Form RI 30-10 requires approximately 60 minutes for completing. The annual burden of
2,500 hours is estimated.

Form Name

Form Number

No. of Respondents

No. of Responses per Respondent

Average Burden per Response (in hours)

Total Annual Burden (in hours)

Average Hourly Wage Rate

Total Annual Respondent Cost

Disabled Dependent Questionnaire

RI 30-10

2,500

1

1 hour

2,500

$0

$0

We estimate that respondents pay $100 to $150 to obtain needed medical records and physician’s statements. They do not necessarily have to get a special medical evaluation to fulfill the OPM requirements.


13. There is no change in the respondent burden.

14. The annualized cost to the Federal government is $7,725. This cost was determined by
employee salary hours devoted to the program, forms cost, and overhead.


15. N/A


16. No information collected from the form will be published.


17. The Retirement Services program office is the lone processor of the data collected on
these ICRs from approximately 2.8 million customers. The substance of each information
collection does not substantively change at each OMB renewal cycle, but according to
changes in law and regulation. These forms are printed and published (internet, intranet
and on-board systems) through various agencies for distribution to and implementation
by Government customers. Pursuant to title 5 CFR 1320.8(b)(1), it would not be
appropriate to display the OMB clearance expiration date where the form will not be
revised for the foreseeable future (e.g., because it is used to collect applicant, annuitant,
or beneficiary information required by long-standing statutory provisions), where use of
the paper form is prevalent, and where, accordingly, it will be expensive and burdensome
to restock the paper forms inventory with a new version. Last year, under current practice,
Retirement Services printed approximately 2 million documents subject to OMB clearance
at a cost of approximately $85,000. Our costs would rise substantially if additional
revision cycles are added. Lastly, by adding the OMB clearance expiration date to the
existing format, the end users of OPM’s ICRs may erroneously assume that the expiration
date affects the validity of the information collection when it is the OMB clearance
expiration date and not reflective of the substance. This may lead to additional submissions
by customers, possible litigation and increasing pressures on our Operations workloads.
Therefore, we seek approval to not display the OMB clearance expiration date on the
forms and to communicate version changes to the public via the revision date.


18. There are no exceptions to the certification statement.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleOMB SUPPORTING STATEMENT
AuthorMEMOORE
File Modified0000-00-00
File Created2021-01-21

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