Rehabilitation Maintenance Certificate
1240-0012
August 2018
SUPPORTING STATEMENT
REHABILITATION MAINTENANCE CERTIFICATE
(FORM OWCP-17)
OMB NO. 1240-0012
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 Office of Workers’ Compensation Programs (OWCP) administers the Federal Employees’ Compensation Act (FECA) and the Longshore and Harbor Workers’ Compensation Act (LHWCA). These acts provide vocational rehabilitation services to eligible workers with disabilities. 5 U.S.C. 8111(b) of the FECA provides that OWCP my pay an individual undergoing vocational rehabilitation a maintenance allowance, not to exceed $200 a month. 33 U.S.C. 908(g) of the LHWCA provides that person(s) undergoing such vocational rehabilitation shall receive a maintenance allowance as additional compensation when authorized, not to exceed $100.00 per month Form OWCP-17 is used to collect information necessary to determine the amount of any maintenance allowance to be paid. This information collection is currently approved for use through November 20, 2018.
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.
Form OWCP-17 is submitted to OWCP by contractors it hires to provide vocational rehabilitation services. The contractors submit the form requesting payment of an additional rehabilitation maintenance amount to cover incidental costs incurred by the disabled worker while obtaining vocational rehabilitation services. For example, when a disabled worker attends a training program, Form OWCP-17 may be used to request reimbursement to the disabled worker for out-of-pocket costs such as travel expenses.
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, the current Form OWCP-17 is electronically interactive and posted on the Internet.
http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-17.pdf
The injured worker and rehabilitation counselor may fill out applicable items on the digital version of the form on-line, which includes lines 1 – 9 and 11 – 12. Unless otherwise specified, a paper copy of the form must be printed out in order to obtain the certifications of the injured worker (line 10), rehabilitation facility official (line 13) and the rehabilitation counselor (line 17). The form may then be mailed, faxed or uploaded directly to the OWCP’s online case management system for further action. Once the extension of 1240-0012 is approved, the currently posted version of this form will be updated to reflect the most current expiration date.
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 in this collection is not a duplicate of any information available elsewhere. The respondents are the only sources of the data that are needed to process the request for payment.
If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden
This information collection has been streamlined to obtain the minimum information needed for OWCP to evaluate a proposed rehabilitation plan while imposing the minimum burden on respondents, and does not have a significant economic impact on a substantial number of small entities.
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.
If this information were not collected, OWCP would be unaware of any variations in a respondent’s training schedule and overpayments of maintenance allowances would occur.
Explain any special circumstance.
There are no applicable special circumstances for this information collection.
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.
No outside consultations have taken place concerning the use of the Form OWCP-17. However, OWCP has been evaluating the rehabilitation maintenance allowances for approximately 30 years and has had sufficient experience with Form OWCP-17 to maximize its utility. OWCP has not received any complaints about the manner in which the form has been used. Should any complaints or suggestions for improvement be received they will be carefully evaluated and appropriate action will be taken.
The initial Federal Register Notice inviting public comment was published on June 22, 2018 (83FR29143). The agency did not receive any comments in response to this notice.
Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
There is no gift or payment to respondents other than remuneration to OWCP’s contractors for services and expenses.
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
All OWCP-17s that are submitted are fully protected by the Privacy Act in the following systems of records: DOL/GOVT-1 (FECA); and DOL/ESA-15 (LHWCA). Respondents are informed of this confidentiality by the following statement on the OWCP-17: The information collected will be handled and stored in compliance with the Freedom of Information Act, Privacy Act of 1974 and OMB Cir. No. 130.
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.
There are no questions of a sensitive nature contained on the form.
Provide estimates of the hour burden of the collection of information.
Based upon experience with this form, it is estimated that 370 respondents (rehabilitation counselors) will file 3,452 forms annually, and that it will require 10 minutes for each respondent (rehabilitation counselor) to read instructions, fill in the basic claims information and send the form to OWCP. This estimate is considered to be reasonable since the minimal identifying information requested has been provided to the rehabilitation counselor by OWCP and is thus readily available to them from the case materials they have for the claimant in question.
Because contractors are remunerated for all services and expenses including this information collection, there is no annualized cost of the burden hours to respondents.
3,452 forms X 10 min/60 per hour = 575 hours
Annual Costs to Respondents (capital/start-up & operation and maintenance).
Because respondents are reimbursed for all services and expenses, there are no operation and maintenance costs connected with this information collection.
Provide estimates of annualized cost to the Federal government.
The average OWCP rehabilitation specialist who reviews the form is a GS-12, step 6. The average hourly rate using 2018-RUS, https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/RUS_h.pdf, is $ 41.02. It takes an average of ten minutes to review the form. There are approximately 3,452 forms received annually by both FECA and LHWCA.
Review
Cost: $41.02 x .17 (10min x 1/60) = $6.97 x 3,452 = $24,060
Mailing
Cost: $.53 ($.50 postage/.03 envelope) x 3,452 = 1,830
Processing Cost: $24,060 + 1,830 = $25,890
FECA:
Completed forms are submitted for payment through OWCP’s bill processing contractor at a cost of $1.10 per form.
3,252 forms are paid by the FECA program
Cost = $3,577. ($1.10 x 3,252)
LHWCA:
Completed forms are submitted for payment in the LHWCA program by rehabilitation payment clerks at the average hourly salary of GS-9, step 4 of $26.67 using 2018-RUS. https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/RUS_h.pdf
200 forms are processed for payment (10 minutes) each
Cost = $907 (200 x .17 (10min x 1/60) x $26.67)
Total review/processing cost: $25,890 + 1,830 + 3,577 + 907 = $32,204.
Reimbursement to contractors is made at $90 per hour, at 0.167 or (.17) x 3,452 = $52,816.
Total Federal Costs: $32,204 + 52,816 = $85,020.
Explain the reasons for any program changes or adjustments.
It is noted that there has been a slight change in the number of forms filed annually since the last OMB submission from 2015. The responses from the respondents decreased from 3,752 to 3,452. Accordingly, the burden hours decreased from 625 to 575 an adjustment of 50 hours.
Minor revision to the form is noted below:
Added a line/space to the OWCP Rehabilitation Specialist or Rehabilitation Counselor section to clarify who is required to sign the form.
Changed the font in the fillable sections to improve readability.
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.
This information will not be published.
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 expiration date will be displayed on the form.
Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to the certification.
B. Collections of Information Employing Statistical Methods:
Statistical methods are not used in these collections of information.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | OWCP-16February2002 |
| Author | Sharpless, Marcus J - OWCP |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |