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Proposed Extension of Existing Collections; Comment Request

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The Department of Labor, 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 (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: Claim for Compensation by Dependents Information Reports (CA-5, CA-5b, CA-1031, CA-1074, Letter of Compensation Due at Death, and Letter of Student/Dependency). 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 7, 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 forms included in this package are forms used by Federal employees and their dependents to claim benefits, to prove continued eligibility for benefits, to show entitlement to remaining compensation payments of a deceased employee and to show dependency under the Federal Employees' Compensation Act. There are six items in this information collection request. The information collected by Forms CA-5, is used by dependents for claiming compensation for the work related death of a Federal Employee and 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 and is entitled to additional compensation. Form CA-1074 is a follow up to CA-5b to request clarification of any information that is unclear and incomplete in the CA-5b. The letter of “Compensation Due at Death” 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 scheduled award. The letter of “Student/Dependency” 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. This information collection is currently approved for use through August 31, 2016.

II. Review Focus: The Department of Labor 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 Department of Labor seeks extension of approval to collect this information in order to carry out its responsibility to meet the statutory requirements of the Federal Employees' Compensation Act. The information contained in these forms is used by the Division of Federal Employees' Compensation to determine entitlement to benefits under the Act, to verify dependent status, and to initiate, continue, adjust, or terminate benefits based on eligibility criteria.

Type of Review: Extension.

Agency: Office of Workers' Compensation Programs.

Title: Claim for Compensation by Dependents Information Reports.

OMB Number: 1240-0013.

Agency Number: CA-5, CA-5b, CA-1031, CA-1074, Letter of Compensation Due at Death, and Letter of Student/Dependency.

Affected Public: Individuals or households.

Total Respondents: 933.

Total Responses: 933.Start Printed Page 60458

Form/letterTime to complete (minutes)Frequency of responseNumber of respondentsHours burden
Student Dependency301299150
Comp Due at Death301253127

Estimated Total Burden Hours: 800.

Total Burden Cost (capital/startup): $0.

Total Burden Cost (operating/maintenance): $541.

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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Ajanette Suggs,

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

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[FR Doc. 2019-24359 Filed 11-7-19; 8:45 am]