View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 1240-0029	ICR Reference No: 202309-1240-003
Status: Active	Previous ICR Reference No: 202006-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Request for Examination and/or Treatment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/14/2023
	Date Received in OIRA: 10/10/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2026	36 Months From Approved	12/31/2023
Responses	72,000	0	90,000
Time Burden (Hours)	39,120	0	48,750
Cost Burden (Dollars)	2,700,000	0	2,544,300

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	72,000	90,000	-18,000
Annual Time Burden (Hours)	39,120	48,750	-9,630
Annual Cost Burden (Dollars)	2,700,000	2,544,300	155,700

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden responses and time decreased due error in prior calculation. Stakeholders have the option to use this form or submit initial medical reports. Mailing costs also decreased due to the new SEAPortal system which allows for electronic submission of forms. Burden cost increased due to the increase in the cost of doctor's time and cost of employee and employer time (NAWW).

Annual Cost to Federal Government: $38,985

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

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