Claimant Medical Reimbursement Form

ICR 200011-1215-004

OMB: 1215-0193

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
13922 Migrated
ICR Details
1215-0193 200011-1215-004
Historical Active 199712-1215-001
DOL/ESA
Claimant Medical Reimbursement Form
Extension without change of a currently approved collection   No
Regular
Approved without change 01/29/2001
Retrieve Notice of Action (NOA) 11/28/2000
  Inventory as of this Action Requested Previously Approved
03/31/2004 03/31/2004 01/31/2001
41,907 0 40,500
6,957 0 6,723
15,000 0 0

Claimant Medical Reimbursement Form will be used to collect information necessary to document and adjudicate claims for reimbursement of medical costs paid by the injured employee for services covered under FECA. Without this documentation, proper reimbursement cannot be accomplished.

None
None


No

1
IC Title Form No. Form Name
Claimant Medical Reimbursement Form CA-915

  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 41,907 40,500 0 0 1,407 0
Annual Time Burden (Hours) 6,957 6,723 0 0 234 0
Annual Cost Burden (Dollars) 15,000 0 0 15,000 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.
11/28/2000


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