CLAIMANT REIMBURSEMENT VOUCHER

ICR 198206-1215-015

OMB: 1215-0054

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
168416 Migrated
ICR Details
1215-0054 198206-1215-015
Historical Active 197808-1215-013
DOL/ESA
CLAIMANT REIMBURSEMENT VOUCHER
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/30/1982
Approved with change 06/30/1982
Retrieve Notice of Action (NOA) 06/30/1982
  Inventory as of this Action Requested Previously Approved
09/30/1983 09/30/1983 09/30/1983
48,000 0 48,000
8,000 0 8,000
0 0 0

REPORT IS COMPLETED BY BLACK LUNG CLAIMANT SO THAT HE/SHE MAY REQUEST REIMBURSEMENT FOR REASONABLE AND NECESSARY COST OF TRAVEL INCURRED AS A RESULT OF SUBMITTING TO A PHYSICAL EXAMINATION AT THE REQUEST OR CONCURRENCE OF AN ADJUDICATION OFFICER (30 USC 901).

None
None


No

1
IC Title Form No. Form Name
CLAIMANT REIMBURSEMENT VOUCHER CM-957

  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 48,000 48,000 0 0 0 0
Annual Time Burden (Hours) 8,000 8,000 0 0 0 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.
06/30/1982


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