Claim for Reimbursement for Emergency Medical Care

Forms and Documents

Document Name	Status
Form SSS FORM 166 Claim for Reimbursement for Emergency Medical Care Form and Instruction	Modified
SSS FORM 166 SUPPORTING STATEMENT.pdf Supporting Statement B	2008-07-24
SSS FORM 166.pdf Supporting Statement A	2008-07-24

IC Document Collections

IC ID	Document Title	Status
35554	Claim for Reimbursement for Emergency Medical Care Form and Instruction	Modified

ICR Details

OMB Control No: 3240-0030	ICR Reference No: 200807-3240-018
Status: Historical Inactive	Previous ICR Reference No: 200506-3240-002
Agency/Subagency: SSS	Agency Tracking No:
Title: Claim for Reimbursement for Emergency Medical Care
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 08/19/2008
	Date Received in OIRA: 07/24/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved	11/30/2008
Responses	0	0	1
Time Burden (Hours)	0	0	1
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 143	07/24/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 143	07/24/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

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

---

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/24/2008

---