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Application And Statement Of Sickness, Miscarriage, Or Childbirth
APPLICATION AND STATEMENT OF SICKNESS, MISCARRIAGE, OR CHILDBIRTH
OMB: 3220-0095
IC ID: 177107
OMB.report
RRB
OMB 3220-0095
ICR 197910-3220-007
IC 177107
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0095 can be found here:
1981-02-19 - Reinstatement with change of a previously approved collection
1979-12-27 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
APPLICATION AND STATEMENT OF SICKNESS, MISCARRIAGE, OR CHILDBIRTH
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
SI-2
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
2,000
0
0
0
0
2,000
Annual IC Time Burden (Hours)
1,000
0
0
0
0
1,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.