Information Collection

Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident

IC 28284 under ICR 200304-2900-001 · OMB 2900-0104.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4176				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,408	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,408	8	4,400
Annual IC Time Burden (Hours)	2,204	4	2,200
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.