Information Collection

Report Of Personal Injury Or Loss Of Life

IC 140358 under ICR 198105-2115-003 · OMB 2115-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2115-0004 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REPORT OF PERSONAL INJURY OR LOSS OF LIFE	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CG-924E				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,850	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,850	250	2,600
Annual IC Time Burden (Hours)	941	83	858
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.