1240-0013 Spt Stmt final 06 2020

Claim for compensation by Dependents Information Reports

(CA-5, CA-5b, CA-1031, CA-1074)

1240-0013

February 2020

SUPPORTING STATEMENT

CLAIM FOR COMPENSATION BY DEPENDENTS INFORMATION REPORTS

OMB NO: 1240-0013

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 forms included in this package are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation Act from federal employees/their dependents/ survivors; to prove continued eligibility for benefits; to show entitlement to remaining compensation payments of a deceased employee; and to show dependency. The following Codes of Federal Regulations for this OMB apply to Claims for Compensation under the Federal Employees’ Compensation Act, as amended: 20 CFR 10.7, 10.105, 10.410, 10.413, 10.417, 10.535, 10.537. See 5 U.S.C. Sections 8110, 8124, 8145, and 8149.

http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&SID=c131552afa82be329e42e2c9d62a41c8&rgn=div5&view=text&node=20:1.0.1.2.2&idno=20

https://www.dol.gov/owcp/dfec/regs/statutes/feca.htm

Form CA-5 and CA-5b (20 CFR 10.7) are claim forms prescribed in the regulations for use by dependents for claiming compensation for the work related death of a Federal employee. Form CA-5 is used by a surviving spouse or children. Form CA-5b is used by other survivors.

Form CA-1031 is used in disability cases and provides information to determine whether a claimant is actually supporting a dependent (5 U.S.C. 8110) and is entitled to additional compensation.

Form CA-1074 is used as a follow-up to Form CA-5b to request clarification of any information that is unclear or incomplete in the CA-5b. Only those questions that are necessary to make a determination of eligibility are asked.

The "Compensation Due at Death" letter is used to request information necessary to distribute compensation due when an employee dies who was receiving or who was entitled to compensation at the time of death for either disability benefits or a schedule award.

The "Student/Dependency" letter is used to obtain information regarding the student status of a dependent. When a child reaches 18 years of age, they are no longer considered an eligible dependent unless they are a full time student or incapable of self-support.

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.

Claims examiners from the Office of Workers' Compensation Programs (OWCP) use the information obtained by the forms and letters described to determine entitlement to benefits under the Federal Employees' Compensation Act. These forms are reviewed to verify dependents/survivors. Benefit payments are then initiated, continued, adjusted, or terminated accordingly. Without the information requested by the forms, determinations regarding entitlement to benefits could not be made, and OWCP could not ensure that compensation was paid to the correct individuals at the correct rate. Failure to verify dependent information could result in significant overpayment, which would be very difficult to recover.

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 Division of Federal Employees’ Compensation (DFEC) allows individuals and entities that correspond with the Federal Employees’ Compensation Act the option to submit information or transact with the agency electronically, where practicable, and to maintain records electronically where appropriate. The Forms CA-5, CA-5b, CA-1031, and CA-1074 can be downloaded from the following website:

http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm.

For numerous reasons, including but not limited to the low volume of usage and cost, and the fact that Forms CA-1031 and CA-1074 are initiated by OWCP, not by the general public, these forms are not electronically interactive. OWCP contends that this level of automation is not practicable for these forms. The "Compensation Due at Death" and "Student/Dependency" letters are initiated solely by OWCP after the Office performs computer matches on an ongoing basis to assist in determining whether benefits are being paid appropriately.

However, to improve upon the capabilities for the public to submit DFEC documents, OWCP has developed an alternative to mailing of documents. This application, known as The Employee Compensation Operations and Management Portal (ECOMP) is internet based, and allows the users the ability to submit these forms electronically into their respective case record. This application is available to the claimant, employing agency, and the medical provider. There is no cost to the claimant.

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 requested on these forms is not duplicative of any information available elsewhere. The beneficiary is the only source of the required information.

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

Forms CA-5, CA-5b, CA-1074, and Letter "Compensation Due at Death" are required only once, to establish dependent/eligibility status. Without the information requested, no determination could be made regarding the payment of benefits.

Letter of "Student/Dependency" is used by OWCP to determine a claimant’s entitlement to augmented compensation. At least once each year, OWCP may ask an employee who receives compensation based in part on the student status of a child, to provide proof of continuing entitlement to such compensation, including certification of school enrollment.

Also, at least once each year, OWCP will ask an employee who receives compensation based on a child's physical or mental inability to support himself or herself, to submit a medical report verifying that the child's medical condition persists and that it continues to preclude self- support.

The CA-1031 is sent only as needed, but no more often than once a year. If these requests were sent less often, overpayments of compensation could occur which would be costly to recapture and impose a burden on the beneficiary.

7. Explain any special circumstance.

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.

A Federal Register Notification inviting public comment was published on November 8, 2019 (84 FR 60457). 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 gifts are 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 contained in FECA claim files is fully protected under the Privacy Act. All forms used for initiating a compensation claim contain a statement advising the claimant of the provisions of the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1 at website: http://www.dol.gov/sol/privacy/dol-govt-1.htm (81 FR 47418).

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.

Forms CA-5, CA-5b, CA-1074, and the Student Dependency Letters include a Privacy Act statement that defines when and for what purposes may be disclosed, The Privacy Act Statements on the forms will read as follows:

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.

12. 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.

The burden for most of these forms was determined by estimating the total number of these forms received during the calendar year period between 2016 and 2018.

The time required to complete each form is based upon reviewing each form and estimating the time necessary to obtain the required information and complete the form, both by the claimant or beneficiary, and the person providing certification of the information. The combined burden hours have been calculated to be 800.

Because the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage for production or nonsupervisory workers on private non-agriculture payrolls as computed by BLS is $27.99 per hour—for a total respondent cost burden of $22,393.00.

Estimated Annualized Respondent Hour and Cost Burdens

Form/Letter	Number of Respondents	Number of Responses per Respondents	Total Number of Responses	Average Burden per Response (in Hours)	Total Burden Hours	Hourly Wage Rate*	Total Burden Costs
CA-5/5bs	333	1	333	1.5	500	$27.99	$13,995
CA-1031	38	1	38	.33	13	$27.99	364
CA-1074	10	1	10	1	10	$27.99	280
Student Dependency Letter	299	1	299	.5	150	$27.99	4,199
Comp Due at Death Letter	253	1	253	.5	127	$27.99	3,555
Totals	933		933		800	$27.99	$22,393

*

See website:

https://www.bls.gov/news.release/empsit.b.htm

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

The only operation and maintenance cost is for postage and envelope (933 responses at $.58 per response = $ 541.00.

Total claimant costs [$0.55 (postage) + $0.03 (envelopes)] x 933(forms) =$ 541.00

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

Review Costs: The average hourly wage for the reviewer is that of a GS-12/6 $41.70.

See website:

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2019/RUS_h.pdf

Form/Letter	Time to Review	Number of Respondents	Costs
CA-5/5b	30 minutes	333	$6,943
CA-1031	30 minutes	38	792
CA-1074	30 minutes	10	209
Student Dependency	9 minutes	299	1,870
CompDue at Death	19.8 minutes	253	3,482
Totals		933	$13,296

Federal Cost Estimate:

Printing Cost: Due to the small number of claims received for the CA-5 and CA-5b, there are no plans to print the form in bulk for distribution. All other forms are generated by the word processing program in the automated system in each district office.

Mailing and Envelope Cost: $0.55 (postage) + $0.03 (envelope) x 933 = $541.

The total Federal cost for mailing and processing of these documents is $13, 837 ($13, 296.00 + $541.00)

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

This reinstatement is being made without a change to bring back into compliance as it has expired.

The estimated number of annual respondents (933) is a decrease of (742) from the previous request of (1, 675). The estimate in burden hours (800) is a decrease of (164) from the previously approved (964).

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.

Data collected with these forms will not be published.

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 OMB Number and expiration date will be displayed.

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

There are no exceptions to certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.