View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Claim for Medical Reimbursement Form
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 725.705
20 CFR 10.802
20 CFR 725.701
20 CFR 30.702
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
OWCP-915
Claim for Medical Reimbursment
OWCP-915.pdf
http://www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf
Yes
No
Fillable Printable
Form and Instruction
OWCP-915 (Revised Draft)
Claim for Medical Reimbursement
OWCP-915 (draft for 2006 renewal).pdf
http://www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)
FR Citation:
67 FR 67
Number of Respondents:
21,396
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
85,584
0
0
-50,444
0
136,028
Annual IC Time Burden (Hours)
14,207
0
0
-8,373
0
22,580
Annual IC Cost Burden (Dollars)
103,557
0
0
-60,443
0
164,000
Documents for IC
Title
Document
Date Uploaded
FECA 20 cfr 10.802
FECA 20 CFR 10.802.pdf
08/21/2006
EEOICPA 20 CFR 30.702
EEOICPA 20 CFR 30.702.pdf
08/21/2006
BLBA 20 CFR 725.701 and 20 CFR 725.705
BLBA 20 CFR 725.701and 725.705.pdf
08/21/2006
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.