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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Request for State or Federal Workers' Compensation Information
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 725.535
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CM-905
Request for State or Federal Workers' Compensation Information
CM-905.doc
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Survivor Compensation
Privacy Act System of Records
Title:
DOL/ESA-30
FR Citation:
67 FR 16878
Number of Respondents:
2,000
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
2,000
0
0
600
0
1,400
Annual IC Time Burden (Hours)
500
0
0
150
0
350
Annual IC Cost Burden (Dollars)
980
0
0
322
0
658
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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