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Request for Examination and/or Treatment (Employee Burden)
Request for Examination and/or Treatment
OMB: 1240-0029
IC ID: 197372
OMB.report
DOL/OWCP
OMB 1240-0029
ICR 201412-1240-009
IC 197372
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0029 can be found here:
2023-10-10 - Revision of a currently approved collection
2020-10-30 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Request for Examination and/or Treatment (Employee Burden)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 702.419
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
DOL/GOVT-15
FR Citation:
67 FR 16870
Number of Respondents:
48,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
48,000
0
0
0
0
48,000
Annual IC Time Burden (Hours)
44,000
0
0
0
0
44,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.