MEDICAL TRAVEL REFUND REQUEST

ICR 198607-1215-002

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
121962 Migrated
ICR Details
1215-0054 198607-1215-002
Historical Active 198309-1215-005
DOL/ESA
MEDICAL TRAVEL REFUND REQUEST
Revision of a currently approved collection   No
Regular
Approved without change 08/05/1986
Retrieve Notice of Action (NOA) 07/15/1986
  Inventory as of this Action Requested Previously Approved
08/31/1989 08/31/1989 09/30/1986
72,000 0 48,160
12,000 0 7,224
0 0 0

THE MINER TRAVEL REFUND REQUEST, CM-957, IS USED BY ELIGIBLE MINERS TO DOCUMENT A REQUEST FOR REIMBURSEMENT OF TRAVEL EXPENSES RELATED TO BLA LUNG MEDICAL TESTING AND TREATMENT.

None
None


No

1
IC Title Form No. Form Name
MEDICAL TRAVEL REFUND REQUEST 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 72,000 48,160 0 0 23,840 0
Annual Time Burden (Hours) 12,000 7,224 0 0 4,776 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.
07/15/1986


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