Supporting Statement 1240-0047 (CA-1027) OCIO1

Request for Employment Information

OMB Control Number: 1240-0047

OMB Expiration Date: August 31, 2025

SUPPORTING STATEMENT

REQUEST FOR EMPLOYMENT INFORMATION

(FORM CA-1027)

OMB CONTROL NO. 1240-0047

This ICR seeks to extend this information collection.

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

5 U.S.C. § 8106 requires payment of compensation for partial disability to injured Federal employees.  This section also requires the Office of Workers' Compensation Programs (OWCP) to obtain information regarding a claimant's earnings during a period of eligibility to compensation.  The CA-1027 is used to obtain earning information for an individual who is employed by a private employer.  This information is used to determine the claimant's entitlement to compensation benefits.

See: https://www.dol.gov/agencies/owcp/FECA/regs/statutes/feca

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The information collected is used by claims examiners for OWCP to determine the appropriate level of benefits to be paid to a claimant. The employer is asked to provide the claimant's job title and brief description of duties performed; the number of hours worked per week; the inclusive dates of employment; the weekly rate of pay, exclusive of overtime, but including the value of any board lodging, or other advantages received in addition to or in lieu of wages; any change in the rate of pay and the approximate date of each change; and, if the claimant is no longer employed, an explanation regarding why.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act (GPEA), the United States (US) Department of Labor (DOL) recognizes the requirement that all Office of Management and Budget (OMB) Forms be made electronically interactive. The CA-1027, Request for Employment Information, has been reviewed with consideration of this goal.

The CA-1027 is initiated by OWCP when there is evidence of earnings. This letter is not a candidate for placement on the OWCP website for printing or downloading due to the low volume usage of the CA-1027.

3. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

The information collected via the CA-1027 is not duplicated anywhere within OWCP or any other Federal agency.

3. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden

This information collection does not have a significant economic impact on a substantial number of small entities.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

If this information were requested less frequently, claimants could receive compensation to which they were not entitled, creating overpayments which are often difficult to recover.

6. Explain any special circumstance that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentially that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentially to the extent permitted by law.

There are no special circumstances required in the collection of this information.

6. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically, address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years – even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

One comment was received that was outside of the scope of this collection. To comply with M-22-10, the individuals/organizations consulted about the information collection are listed in the table below.  We reached out to the following individuals, but we did not receive any responses. We have redacted their names and contact information.

Contact	Organization	Email	Phone
Jennifer XXXX	UVA	XXX	XXX
Eric XXXX	Dupos Express	XXX	XXX
Marie XXXX	Life Path Systems	XXX	XXX

A Federal Register Notice inviting public comment was published on March 11, 2025 (90 FR 11755). A comment was received stating: “This agency collection should not be associated with employment verification of the Private Sector nor salary details and needs to be terminated due to violations of the contract.” Although the commenter disagreed with a request for private sector earnings and employment verification, accurate reporting of outside earnings, including private sector earnings, may be required under 5 U.S.C. §8106, for OWCP to determine their entitlement to compensation benefits.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts are provided to respondents.

9. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

The information collected by these forms is maintained in FECA claim files, which are fully protected under the Privacy Act. The applicable Privacy Act system of records is DOL/GOV-1 [81 Fed. Reg. 418 (July 21, 2016)]. The Privacy Act Statement has been added to this form associated with this information collection.

See: http://www.dol.gov/sol/privacy/dol-govt-1.htm.

9. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature contained on the form.

9. Provide estimates of the hour burden of the collection of information.

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. General, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses Per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Monetized Value of Respondent Time
CA-1027	10	1	10	.25	3 (rounded)	$30.62	$92.00 (rounded)

The average number of respondents (who are private employers) is 10. This figure is based on requests for information related to a claimant’s employment for calendar years 2022-2024.   The information requested on the form is readily available to the respondents.  It is estimated that the form can be completed in an average of 15 minutes, including time to look up the information and complete the form.  The total burden hours have been calculated as (0.25 x 10) = 2.5 or 3 rounded.

The monetized value of respondent time to provide a response to the form is calculated using an estimated hourly rate of $30.62. This is because the wage category of the respondent is unknown and is therefore based on the National Average Weekly Wage for production or non-supervisory workers on private nonagricultural payrolls as computed by using the Bureau of Labor Statistics, December 2024 Current Employment Statistics. Table B-8 Average hourly and weekly earnings or production non-supervisory employees on private nonfarm payrolls by industry sector, seasonally adjusted. The computation is therefore as follows: ($30.62/hr. x 3 = $92.00 rounded).

See: https://www.bls.gov/news.release/empsit.t24.htm

9. Provide an estimate of the total annual cost burden or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and startup cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of service component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

This information collection does not require the use of systems or technology for generating, maintaining, or disclosing the data above which would already be kept as a customary business practice.

The annual operating and mailing cost of respondents is $7.30 ($0.73 x 10 respondents = $7.30 or $7.00 rounded). The $0.76 is based on postage of $0.73 + $0.03 per envelope, per response. Operation costs and amounts equates to $7.60 ($0.76 x 10 = $7.60 or $8.00 rounded).

The total combined costs for FECA respondents are $8.00.

14. Provide estimates of annualized cost to the Federal government.

This form is printed by the OWCP’s automated Correspondence Library when prompted by a Claims Examiner.  Approximately 10 requests are reviewed on an annual basis. The request is reviewed by a Claims Examiner with an average grade of GS-12/Step 8, at an hourly rate of $52.37.

See: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2025/RUS_h.pdf

Review of the incoming responses averages about twenty minutes (.33). In addition, a mailing cost of $0.76 (based on postage of $0.73 + $.03 per envelope, per response) to the respondent is associated with each response. Therefore, the computations are as follows:

Review Cost: 10 x (.33) x $52.37 h = $172. or $173.00 rounded

Mailing Cost: 10 x $0.76 = + $7.60 or $8.00 rounded

Total Federal Costs:

Description	Cost
Review Cost	$173.00
Mailing Costs	$8.00
TOTAL	$181.00 (rounded)

15. Explain the reasons for any program changes or adjustments.

The previously approved number of respondents was 10. The current number of respondents is 10. Consequently, the burden hours have remained the same.

There were no adjustments or planned changes to this letter at this time.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

This information will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

No exception is requested for the display of the OMB number and expiration date.

18. Explain each exception to the certification statement identified in ROCIS.

There are no exceptions to the certification.

B. Collections of Information Employing Statistical Methods:

Statistical methods are not used in these collections of information.

8