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: 1240-0024	ICR Reference No: 202311-1240-006
Status: Active	Previous ICR Reference No: 202012-1240-007
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Certificate of Medical Necessity
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: 04/26/2024
	Date Received in OIRA: 03/25/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2027	36 Months From Approved	05/31/2024
Responses	1,500	0	1,300
Time Burden (Hours)	563	0	488
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	1,500	1,300	200
Annual Time Burden (Hours)	563	488	75
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: EXPLANATION OF CHANGE TOTALS Respondents: The number of respondents increased from 1,300 to 1,500. Responses: The number of responses increased from 1,300 to 1,500. Burden Hours: Total burden hours increased from 488 to 563 due to the increased of forms received. Costs: Annual burden costs remains $0.0 to the respondents, since the operational and maintenance costs associated with the collection of this information are reimbursed.

Annual Cost to Federal Government: $242,382

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

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