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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:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
20 CFR 30.702
20 CFR 10.802
20 CFR 725.705
20 CFR 725.701
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 Reimbursement
OWCP-915_revised.pdf
http://www.dol.gov/esa/owcp/dfec/regs/complince/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 16826
Number of Respondents:
10,632
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
38,480
0
0
12,608
0
25,872
Annual IC Time Burden (Hours)
6,388
0
0
2,094
0
4,294
Annual IC Cost Burden (Dollars)
68,879
0
0
26,190
0
42,689
Documents for IC
Title
Document
Date Uploaded
FECA 20 CFR10.802
FECA 20 CFR 10.802.pdf
10/24/2012
EEOICPA 20 CFR 30.702
EEOICPA 30 CFR 30.702.pdf
10/24/2012
BLBA 20 CFR 725.701 and 20 CFR 725.705
BLBA 20 CFR 725.701 and 725.705.pdf
10/24/2012
EEOICPA 20 CFR 30.701 Proposed
CFR-2015-title20-vol1-sec30-701 EEOICPA proposed.pdf
11/02/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.