Medical Travel Refund Request

ICR 201003-1240-037

OMB: 1240-0037

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2007-05-02
Supplementary Document
2007-03-28
Supplementary Document
2007-03-28
Supplementary Document
2007-03-28
IC Document Collections
IC ID
Document
Title
Status
38444 Modified
ICR Details
1240-0037 201003-1240-037
Historical Active 200506-1215-007
DOL/OWCP
Medical Travel Refund Request
Extension without change of a currently approved collection   No
Regular
Approved without change 03/12/2010
Retrieve Notice of Action (NOA) 03/12/2010
  Inventory as of this Action Requested Previously Approved
08/31/2010 36 Months From Approved
163,236 0 54,098
27,097 0 8,982
68,559 0 21,000

This form is used to request reimbursement for out-of-pocket expenses incurred when traveling to medical providers for covered medical testing or treatment.

US Code: 5 USC 8101 Name of Law: Federal Employees' Compensation Act (FECA)
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
  
None

Not associated with rulemaking

  72 FR 2309 01/18/2007
72 FR 28552 05/21/2007
No

1
IC Title Form No. Form Name
Medical Travel Refund Request OWCP-957 Medical Travel Refund Request

  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 163,236 54,098 0 0 109,138 0
Annual Time Burden (Hours) 27,097 8,982 0 0 18,115 0
Annual Cost Burden (Dollars) 68,559 21,000 0 0 47,559 0
No
No
There has been a significant increase in the number of reimbursement requests filed for the FECA program and as a result there is an increase from 8,982 burden hours to 27,097 burden hours which is an adjustment increase of 18,115 burden hours. Also due to the increase in mailed responses the operation and maintenance cost has increased from $21,000 to $68,559 which is an adjustment of $47,559.

$1,658,879
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Sheldon Turley 202-693-5337 [email protected]

  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.
05/22/2007


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