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Proposed Extension of Existing Collection; Comment Request

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Division of Federal Employees' Compensation, Office of Workers' Compensation Programs, Labor.




The Department of Labor (DOL), as part of its continuing effort to reduce paperwork and respondent burden, conducts a preclearance consultation program to provide the general public and Federal agencies with an opportunity to comment on proposed and/or continuing collections of information in accordance with the paperwork Reduction Act of 1995 (PRA95). This program helps to ensure that requested data can be provided in the desired format, reporting burden Start Printed Page 59653(time and financial resources) is minimized, collection instruments are clearly understood, and the impact of collection requirements on respondents can be properly assessed.

Currently, the Office of Workers' Compensation Programs is soliciting comments concerning the proposed collection: Death Gratuity Forms CA-40, CA-41, and CA-42. A copy of the proposed information collection request can be obtained by contacting the office listed below in the addresses section of this Notice.


Written comments must be submitted to the office listed in the addresses section below on or before January 6, 2020.


You may submit comments by mail, delivery service, or by hand to Anjanette Suggs, U.S. Department of Labor, 200 Constitution Ave. NW, Room S-3323, Washington, DC 20210; by fax, (202) 354-9660, or email to Please use only one method of transmission for comments (mail or email).

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I. Background

The DOL is requesting an approval of an extension of this information collection. This information collection is essential to the mission of DOL and the Office of Workers' Compensation Programs (OWCP), the information collected through forms CA-40, CA-41 and CA-42 is used by claims examiners in OWCP to determine a person's entitlement to any or all of the death gratuity payment provided by 5 U.S.C. § 8102a. The National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181, was enacted on January 28, 2008. Section 1105 of Public Law 110-181 amended the Federal Employees' Compensation Act (FECA) creating a new section, 5 U.S.C. 8102a effective upon enactment. This section establishes a FECA death gratuity benefit of up to $100,000 for eligible beneficiaries of federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die from injuries incurred in connection with service with an Armed Force in a contingency operation. 5 U.S.C. 8102a also permits agencies to authorize retroactive payment of the death gratuity for employees who died on or after October 7, 2001 in service with an Armed Force in the theater of operations of Operation Enduring Freedom and Operation Iraqi Freedom. 5 U.S.C. 8102a also allows federal employees to vary the order of precedence of beneficiaries or to name alternate beneficiaries. 20 CFR 10.909 and 10.911 provides that forms CA-40, CA-41, and CA-42 are used to designate beneficiaries and initiate the payment process for death gratuity benefits. See 5 U.S.C. 8145 and 8149.

Form CA-40 is an optional form that requests the information necessary from the employee to accomplish this variance and to name alternate beneficiaries only if the employee wishes to do so. Form CA-41 provides the means for those named beneficiaries and possible recipients to file claims for those benefits and requests information from such claimants so that OWCP may determine their eligibility for payment. Further, the statute and regulations require agencies to notify OWCP immediately upon the death of a covered employee. CA-42 provides the means to accomplish this notification and requests information necessary to administer any claim for benefits resulting from such a death.

II. Review Focus

The DOL is particularly interested in comments which:

* Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility;

* Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used;

* enhance the quality, utility and clarity of the information to be collected; and

* minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submissions of responses.

III. Current Actions

The DOL seeks the approval for the extension of this currently approved information collection in order to carry out its responsibility to meet the statutory requirements of the Federal Employees' Compensation Act.

Agency: Office of Workers' Compensation Programs.

Type of Review: Extension.

Title: Death Gratuity Forms.

OMB Number: 1240-0017.

Agency Number: CA-40, CA-41, and CA-42.

Affected Public: Individuals or households; Businesses or other for-profit.

Total Respondents: 4.

Total Annual Responses: 4.

Estimated Total Burden Hours: 3.

Estimated Time per Response: 30 minutes.

Frequency: On occasion.

Total Burden Cost (capital/startup): $84.

Total Burden Cost (operating/maintenance): $2.

Comments submitted in response to this notice will be summarized and/or included in the request for Office of Management and Budget approval of the information collection request; they will also become a matter of public record.

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Anjanette Suggs,

Agency Clearance Officer, Office of Workers' Compensation Programs, U.S. Department of Labor.

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[FR Doc. 2019-24083 Filed 11-4-19; 8:45 am]