Information Collection

Request for State or Federal Workers' Compensation Information

IC 13703 under ICR 201008-1240-001 · OMB 1240-0032.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0032 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-905 Request for State or Federal Workers' Compensation Information	Form
CM-905 Request for State or Federal Workers' Compensation Infor CM-905.doc	Form

IC Title:

Request for State or Federal Workers' Compensation Information

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 725.535

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	CM-905	Request for State or Federal Workers' Compensation Information	CM-905.doc		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/ESA-30

FR Citation: 67 FR 16878

Number of Respondents: 1,400

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	1,400	0	1,400
Annual IC Time Burden (Hours)	350	0	350
Annual IC Cost Burden (Dollars)	658	42	616

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.