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:
1240-0037
ICR Reference No:
202008-1240-070
Status:
Historical Active
Previous ICR Reference No:
202002-1240-012
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Medical Travel Refund Request
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/22/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/22/2020
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2021
06/30/2021
06/30/2021
Responses
333,528
0
333,528
Time Burden (Hours)
55,366
0
55,366
Cost Burden (Dollars)
173,435
0
173,435
Abstract:
Requesting address change to OWCP-957 form. This form is used to request reimbursement for out-of-pocket expenses incurred when traveling to medical providers for covered medical testing or treatment.
Authorizing Statute(s):
US Code:
30 USC 901
Name of Law: Black Lung Benefits Act (BLBA)
US Code:
42 USC 7384
Name of Law: Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
US Code:
5 USC 8101
Name of Law: Federal Employees' Compensation Act (FECA)
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:
81 FR 73142
10/24/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 95649
12/28/2016
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
Medical Travel Refund Request
OWCP-957
Medical Travel Refund Request
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
333,528
333,528
0
0
0
0
Annual Time Burden (Hours)
55,366
55,366
0
0
0
0
Annual Cost Burden (Dollars)
173,435
173,435
0
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:
Annual Cost to Federal Government:
$1,511,637
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?
No
Agency Contact:
Anjanette Suggs 202 354-9660 suggs.anjanette@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:
10/22/2020
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