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Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202104-1240-001 · OMB 1240-0016 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CA-1032 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements Form and Instruction Modified Available
1240-0016 Supporting Statement final.docx Supporting Statement A Uploaded 2022-01-14 Repair queued
20 cfr 10.528.docx Supplementary Document Uploaded 2020-03-20 Repair queued
DOL GOVT-1.docx Supplementary Document Uploaded 2020-03-20 Repair queued
opm salary table 2020.pdf Supplementary Document Uploaded 2020-03-20 Repair queued
Average hourly and weekly earnings of production and nonsupervisory employees on private nonfarm payrolls by industry sector, seasonally adjusted.docx Supplementary Document Uploaded 2020-03-20 Repair queued
5 USC Sections 8105, 8106, 8110, 8132 and 8148.docx Supplementary Document Uploaded 2020-03-20 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
13834 Request for Information on Earnings, Dual Benefits, Dependents, and Third Part Settlements Form and Instruction Modified
ICR Details
1240-0016 202104-1240-001
Received in OIRA 202003-1240-006
DOL/OWCP
Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
Revision of a currently approved collection   No
Regular 01/21/2022
  Requested Previously Approved
11/30/2023 11/30/2023
37,056 37,056
12,228 12,352
15,030 15,030
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.
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
  
None
Not associated with rulemaking
  86 FR 30335 06/06/2021
87 FR 3355 01/21/2022
No
  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
No
No
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.
$426,539
No
    Yes
    Yes
No
No
No
No
Marcus Sharpless 202 693-0998 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/21/2022