Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements

Forms and Documents

Document Name	Status
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements Form and Instruction	Modified
1240-0016 Supporting Statement final.docx Supporting Statement A	2022-01-14
20 cfr 10.528.docx Supplementary Document	2020-03-20
DOL GOVT-1.docx Supplementary Document	2020-03-20
opm salary table 2020.pdf Supplementary Document	2020-03-20
Average hourly and weekly earnings of production and nonsupervisory employees on private nonfarm payrolls by industry sector, seasonally adjusted.docx Supplementary Document	2020-03-20
5 USC Sections 8105, 8106, 8110, 8132 and 8148.docx Supplementary Document	2020-03-20

IC Document Collections

IC ID	Document Title	Status
13834	Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0016	ICR Reference No: 202104-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202003-1240-006
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/21/2022

	Requested	Previously Approved
Expiration Date	11/30/2023	11/30/2023
Responses	37,056	37,056
Time Burden (Hours)	12,228	12,352
Cost Burden (Dollars)	15,030	15,030

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Abstract: Form CA-1032 is used to obtain information from claimants receiving compensation for an extended period of time. This information is necessary to ensure that compensation being paid is correct.

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Authorizing Statute(s): US Code: 5 USC 8116 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8132 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8148 Name of Law: Federal Employees' Compensation Act
   US Code: 5 USC 8110 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:
	86 FR 30335	06/06/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 3355	01/21/2022
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
Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements	CA-1032	Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlement

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ICR Summary of Burden

	Total Request	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	37,056	37,056	0	0	0	0
Annual Time Burden (Hours)	12,228	12,352	0	0	-124	0
Annual Cost Burden (Dollars)	15,030	15,030	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: There are no changes with the previous submission related to number of respondents and IC cost burden dollars, which remains 37,056, and $15,030, respectively. However, the previously approved burden hours, 12,352, is reduced to 12,228 (a decrease of 124) due to rounding of the average burden hour to “.33 versus .33333333333”. In addition, the revision to this ICR only affects a change to a question in PART D--OTHER FEDERAL BENEFITS OR PAYMENTS of Form CA-1032. This change was necessary to help clarify the question regarding the respondent's receipt of Social Security benefits in conjunction with Federal Employees' Retirement System (FERS) benefits due to Federal service. Such receipt receipt requires an offset from compensation benefits for disability and the question was rephrased to better clarify the information needed. Specific changes are noted as follows and are outlined in Question15 of the Supporting Statement.

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Annual Cost to Federal Government: $426,539

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? No

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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: 01/21/2022

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