Medical Travel Refund Request

ICR 201306-1240-001

OMB: 1240-0037

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2013-06-05
Supplementary Document
2013-06-05
Supplementary Document
2013-06-05
Supporting Statement A
2013-10-21
IC Document Collections
IC ID
Document
Title
Status
38444 Modified
ICR Details
1240-0037 201306-1240-001
Historical Active 201004-1240-010
DOL/OWCP
Medical Travel Refund Request
Extension without change of a currently approved collection   No
Regular
Approved without change 12/04/2013
Retrieve Notice of Action (NOA) 10/24/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved 12/31/2013
302,794 0 182,535
50,263 0 30,301
148,369 0 85,791

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: 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)
   US Code: 5 USC 8101 Name of Law: Federal Employees' Compensation Act (FECA)
  
None

Not associated with rulemaking

  78 FR 35981 06/14/2013
78 FR 63496 10/24/2013
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 302,794 182,535 0 0 120,259 0
Annual Time Burden (Hours) 50,263 30,301 0 0 19,962 0
Annual Cost Burden (Dollars) 148,369 85,791 0 0 62,578 0
No
No
There has been a significant increase in the number of reimbursement requests filed for the FECA and EEOICPA programs and as a result there is an increase from 30,301 burden hours to 50,263 burden hours which is an adjustment increase of 19,962 burden hours. Also due to the increase in mailed responses the operation and maintenance cost has increased from $85,791 to $148,369 which is an adjustment of $62,578.

$1,494,048
No
No
No
No
No
Uncollected
Yoon Ferguson 202 693-0701 [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.
10/24/2013


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