Information Collection

Medical Travel Refund Request

IC 206325 under ICR 201304-0920-001 · OMB 0920-0962.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medical Travel Refund Request	Form
Medical Travel Refund Request Appendix E WTC Health Program Medical Travel Refund Request.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form	none	Medical Travel Refund Request	Appendix E WTC Health Program Medical Travel Refund Request.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Occupational Health epidemiological Studies and EEOICPA Program Records and WTC Probram Records

FR Citation: 78 FR 31212

Number of Respondents: 1

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 New Statute
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

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.