Information Collection

Medical Report Forms

IC 122147 under ICR 198211-1215-003 · OMB 1215-0103.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0103 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	MEDICAL REPORT FORMS	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.	Available Electronically?	Can Be Submitted Electronically?
Form	CA-16,17,20,	No	No
Form	28,1090,	No	No
Form	1302,1303,	No	No
Form	1304,1306,	No	No
Form	1308,1316,	No	No
Form	1331,	No	No
Form	OWCP-5	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 608,500	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	608,500	500	608,000
Annual IC Time Burden (Hours)	151,708	0	151,708
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.