Medical Travel Refund Request

ICR 199807-1215-006

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
13682 Migrated
ICR Details
1215-0054 199807-1215-006
Historical Active 199506-1215-002
DOL/ESA
Medical Travel Refund Request
Extension without change of a currently approved collection   No
Regular
Approved without change 09/22/1998
Retrieve Notice of Action (NOA) 07/31/1998
Approved consistent with DOL clarification memo of 9-22-98.
  Inventory as of this Action Requested Previously Approved
09/30/2001 09/30/2001 09/30/1998
8,700 0 12,000
1,450 0 2,000
3,000 0 0

This form is used by coal miners requesting reimbursement for out-of-pocket expenses incurred when traveling to medical providers for black lung diagnostic testing or treatment of their black lung disease.

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 8,700 12,000 0 0 -3,300 0
Annual Time Burden (Hours) 1,450 2,000 0 0 -550 0
Annual Cost Burden (Dollars) 3,000 0 0 0 3,000 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.
07/31/1998


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