Claim for Compensation by a Dependent Information Reports

OMB Control No: 1240-0013	ICR Reference No: 201910-1240-002
Status: Historical Active	Previous ICR Reference No: 201602-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Compensation by a Dependent Information Reports
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/15/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved
Responses	933	0	0
Time Burden (Hours)	800	0	0
Cost Burden (Dollars)	541	0	0

---

Abstract: The forms included in this package are used to request information for entitlement to claim benefits under the Federal Employees’ Compensation 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.

---

Authorizing Statute(s): US Code: 5 USC 8124 Name of Law: Federal Employees' Compensation Act    US Code: 5 USC 8145 Name of Law: Federal Employees' Compensation Act    US Code: 5 USC 8110 Name of Law: Federal Employees' Compensation Act    US Code: 5 USC 8149 Name of Law: Federal Employees' Compensation Act

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 60457	11/08/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 21025	04/15/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Claim for Compensation by a Dependent Information Reports CA-5, CA-1031, CA-1074, CA-5b Claimant Support of Dependent ,   Request for Clarification of CA-5b ,   Claim for Compensation by Widow, Widower, and/or Children ,   Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren

---

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	933	0	0	0	-742	1,675
Annual Time Burden (Hours)	800	0	0	0	-164	964
Annual Cost Burden (Dollars)	541	0	0	0	-330	871

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: 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).

---

Annual Cost to Federal Government: $13,837

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

Agency Contact: Marcus Sharpless 202 693-0998 [email protected]

---

Common Form ICR:  No

---

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: 04/15/2020

---