View Information Collection Request (ICR) Package

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: 1240-0044	ICR Reference No: 201208-1240-002
Status: Historical Active	Previous ICR Reference No: 201003-1240-044
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Health Insurance Claim 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: 12/31/2012
	Date Received in OIRA: 11/14/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	12/31/2012
Responses	3,036,067	0	2,996,416
Time Burden (Hours)	322,838	0	359,359
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	3,036,067	2,996,416	39,651
Annual Time Burden (Hours)	322,838	359,359	-36,521
Annual Cost Burden (Dollars)	0	0	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: As the number of electronically submitted responses increase, the number of burden hours decreases. As a result, there is a net adjustment decrease of 36,521 hours.

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.