Notice of Recurrence

ICR 200206-1215-004

OMB: 1215-0167

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
13869 Migrated
ICR Details
1215-0167 200206-1215-004
Historical Active 199906-1215-003
DOL/ESA
Notice of Recurrence
Extension without change of a currently approved collection   No
Regular
Approved without change 07/18/2002
Retrieve Notice of Action (NOA) 06/18/2002
  Inventory as of this Action Requested Previously Approved
07/31/2005 07/31/2005 08/31/2002
550 0 550
275 0 275
0 0 0

This form is used by current, or occasionally former, Federal employees to claim wage loss or medical treatment resulting from a recurrence of a work-related injury while Federally employed. The information is necessary to ensure the accurate payment of benefits.

None
None


No

1
IC Title Form No. Form Name
Notice of Recurrence CA-2A

  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 550 550 0 0 0 0
Annual Time Burden (Hours) 275 275 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.
06/18/2002


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