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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1215-0193
ICR Reference No:
200608-1215-006
Status:
Historical Active
Previous ICR Reference No:
200506-1215-009
Agency/Subagency:
DOL/ESA
Agency Tracking No:
Title:
Claim for Medical Reimbursement Form
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
03/28/2007
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/03/2007
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2010
36 Months From Approved
03/31/2007
Responses
85,584
0
136,028
Time Burden (Hours)
14,207
0
22,580
Cost Burden (Dollars)
103,557
0
164,000
Abstract:
Form OWCP-915 is used to claim reimbursement for out-of-pocket covered medical expenses paid by a beneficiary, and must be accompanied by required billing data elements (prepared by the medical provider) and by proof of payment by the beneficiary.
Authorizing Statute(s):
US Code:
5 USC 8101
Name of Law: Employees Compensation Act
US Code:
30 USC 901
Name of Law: Black Lung Benefits Act
US Code:
42 USC 7384
Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
71 FR 46924
08/15/2006
30-day Notice:
Federal Register Citation:
Citation Date:
71 FR 78224
12/28/2006
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Claim for Medical Reimbursement Form
OWCP-915, OWCP-915 (Revised Draft)
Claim for Medical Reimbursment
,
Claim for Medical Reimbursement
ICR Summary of Burden
Total Approved
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
85,584
136,028
0
0
-50,444
0
Annual Time Burden (Hours)
14,207
22,580
0
0
-8,373
0
Annual Cost Burden (Dollars)
103,557
164,000
0
0
-60,443
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Due to the continuing decline in the number of BLBA beneficiaries currently in the program, and the increase in medical providers billing OWCP directly for medical services rather than billing their patients, who then would have to seek reimbursement from OWCP using Form OWCP-915, shows an adjustment change of -8,372 burden hours and -$60,444 in operational and maintenance costs.
Annual Cost to Federal Government:
$812,703
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Sheldon Turley 202-693-5337 Turley.Sheldon@dol.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
01/03/2007
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