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OMB Control No: 3206-0162	ICR Reference No: 202607-3206-006
Status: Received in OIRA	Previous ICR Reference No: 202404-3206-007
Agency/Subagency: OPM	Agency Tracking No: OPM 1530
Title: Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/23/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	500	500
Time Burden (Hours)	750	750
Cost Burden (Dollars)	24,495	6,719

Annual Cost to Federal Government: $24,150

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: Alexys Stanley 202 606-1183 alexys.stanley@opm.gov

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