Medical Travel Refund Request

Documents and Forms

Document Name Document Type
Form OWCP-957 Medical Travel Refund Request Form and Instruction
OWCP-957 Medical Travel Refund Request OWCP-957 1215-0054.pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Travel Refund Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.315 20 CFR 30.404 20 CFR 725.406 20 CFR 725.701

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-957	Medical Travel Refund Request	OWCP-957 1215-0054.pdf	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 163,236	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	163,236	109,138	54,098
Annual IC Time Burden (Hours)	27,097	18,115	8,982
Annual IC Cost Burden (Dollars)	68,559	47,559	21,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.