View Information Collection Request (ICR) Package
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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:
1240-0007
ICR Reference No:
201805-1240-006
Status:
Historical Active
Previous ICR Reference No:
201606-1240-006
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Claim for Medical Reimbursement Form
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
06/22/2018
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/31/2018
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2021
09/30/2019
09/30/2019
Responses
34,564
0
38,480
Time Burden (Hours)
5,738
0
6,388
Cost Burden (Dollars)
59,450
0
68,879
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:
1240-AA11
Final or interim final rulemaking
83 FR 27690
06/14/2018
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
80 FR 49279
08/17/2015
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 8994
02/23/2016
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
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
34,564
38,480
0
0
-3,916
0
Annual Time Burden (Hours)
5,738
6,388
0
0
-650
0
Annual Cost Burden (Dollars)
59,450
68,879
0
0
-9,429
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:
The agency received 34,564 responses. This results in a decrease of 650 burden hours (6,388 previously approved hours – 5,738 hours = 650 hours). Costs also decreased by $9,429 because of the decreased number of responses ($68,879 previously approved – $59,450 = $9,429). In addition, the final BLBA rule continues the current information collection requirements, but would change where the regulatory authorities are codified. This ICR updates the regulatory citation for the BLBA program’s authority to collect the information.
Annual Cost to Federal Government:
$341,462
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Yoon Ferguson 202 693-0701 ferguson.yoon@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:
05/31/2018
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