View Information Collection Request (ICR) Package

View ICR - Agency Submission

OMB Control No: 1240-0021	ICR Reference No: 202603-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202309-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Provider Enrollment Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 06/29/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2026
Responses	18,417	23,318
Time Burden (Hours)	8,902	9,716
Cost Burden (Dollars)	0	816

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	18,417	23,318	-4,901
Annual Time Burden (Hours)	8,902	9,716	-814
Annual Cost Burden (Dollars)	0	816	-816

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: The changes to form 1168 include changes to the fields and instructions. OWCP is mandating electronic enrollment and only allowing paper/fax submissions in certain extenuating circumstances that make electronic submission impossible. The bill processing system currently allows electronic enrollments and is being enhanced to accommodate the revisions.

Annual Cost to Federal Government: $301,855

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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