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: 1240-0007	ICR Reference No: 202601-1240-001
Status: Active	Previous ICR Reference No: 202404-1240-007
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Medical Reimbursement Form
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: 01/14/2026
	Date Received in OIRA: 01/08/2026
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	07/31/2027	07/31/2027
Responses	54,067	0	54,067
Time Burden (Hours)	9,029	0	9,029
Cost Burden (Dollars)	1,184	0	1,184

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	54,067	54,067
Annual Time Burden (Hours)	9,029	9,029
Annual Cost Burden (Dollars)	1,184	1,184

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: Burden hours have increased from 5,738 to 9,029 due to the increase in claim submissions. The decrease in the operations and maintenances costs is due to the capability of submitting this form electronically.

Annual Cost to Federal Government: $327,505

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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