Information Collection

Request For Certification Of Medical Treatment By Attending Physician

IC 174108 under ICR 198011-2900-026 · OMB 2900-0035.

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Information Collection (IC) Details

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IC Title:	REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN	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	FL21-104				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	32,000	-2,000	34,000
Annual IC Time Burden (Hours)	5,333	-334	5,667
Annual IC Cost Burden (Dollars)	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.