Information Collection

Form B 42 CFR Part 83.9

IC 180183 under ICR 201007-0920-007 · OMB 0920-0639.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment D2 Example of Petition without Form B.rev 1.pdf	Instruction
Attachment D1 SEC Form B Instructions.rev 2.pdf Attachment D1 Form B instructions	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Instruction			Attachment D2 Example of Petition without Form B.rev 1.pdf		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program

FR Citation: 68 FR 55962

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D1 Form B instructions	Attachment D1 SEC Form B Instructions.rev 2.pdf	07/14/2010

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