Claim for Reimbursement for Emergency Medical Care

ICR 200506-3240-002

OMB: 3240-0030

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
35554 Migrated
ICR Details
3240-0030 200506-3240-002
Historical Active 200205-3240-004
SSS
Claim for Reimbursement for Emergency Medical Care
Extension without change of a currently approved collection   No
Regular
Approved with change 08/16/2005
Retrieve Notice of Action (NOA) 06/07/2005
This collection is subject to the Government Paperwork Elimination Act and therefore every effort should be made to provide an electronic option to the public for the form associated with this collection to come into compliance with GPEA as soon as possible. In addition, the Selective Service agrees to submit an 83-C to increase the burden hours accounted for if this collection is activated.
  Inventory as of this Action Requested Previously Approved
08/31/2008 08/31/2008 08/31/2005
1 0 1
1 0 1
0 0 0

This form will be used by a Alternative Service Worker or his estate to initiate a claim for reimbursement of expenses for emergency medical care incurred during the course of an alternative service assignment.

None
None


No

1
IC Title Form No. Form Name
Claim for Reimbursement for Emergency Medical Care SSS-166

  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 1 1 0 0 0 0
Annual Time Burden (Hours) 1 1 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.
06/07/2005


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