HANDICAPPED SERVICES CLAIM FORM

ICR 197806-0704-005

OMB: 0704-0088

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
108631 Migrated
ICR Details
0704-0088 197806-0704-005
Historical Active
DOD/DODDEP
HANDICAPPED SERVICES CLAIM FORM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/20/1978
Retrieve Notice of Action (NOA) 06/09/1978
  Inventory as of this Action Requested Previously Approved
06/30/1983 06/30/1983
30,000 0 0
7,500 0 0
0 0 0

TO COLLECT INFORMATION TO EVALUATE ELIGIBILITY FOR CIVILIAN HEALTH BENEFITS AUTHORIZED BY 10 USC 1079 AND TO ISSUE CHECKS UPON ESTABLISHMENT TO ELIGIBILITY AND DETERMINATION THAT HEALTH BENEFITS RECEIVED ARE AUTHORIZED BY THE STATUTE. USED IN COMPILING STATISTICAL INFORMATION CLAIMS PAID FOR DIAGNOSIS, TREATMENT, TRAINING, REHABILITATION AND INSTITUTIONAL CARE OF PHYSICALLY HANDICAPPED AND MENTALLY RETARDED, COST TO THE GOVERNMENT AND TO THE ACTIVE DUT

None
None


No

1
IC Title Form No. Form Name
HANDICAPPED SERVICES CLAIM FORM CHAMPUS, 1863-3

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 30,000 0 0 0 30,000 0
Annual Time Burden (Hours) 7,500 0 0 0 7,500 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/09/1978


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