Information Collection

Medical Travel Refund Request

IC 38444 under ICR 200611-1215-009 · OMB 1215-0054.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.