Information Collection

Medical Travel Refund Request

IC 38444 under ICR 201004-1240-010 · OMB 1240-0037.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0037 can be found here:

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.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:

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:

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.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: 182,535

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	182,535	19,299	163,236
Annual IC Time Burden (Hours)	30,301	3,204	27,097
Annual IC Cost Burden (Dollars)	85,791	17,232	68,559

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.