Information Collection

Camp Lejeune Family Member Program Claim Form

IC 210895 under ICR 201412-2900-005 · OMB 2900-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0822 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10068a Camp Lejeune Family Member Program Claim Form	Form and Instruction
10-10068a Camp Lejeune Family Member Program Claim Form 10-10068a_CLFM_Claim_Form_508.pdf	Form and Instruction

IC Title:

Camp Lejeune Family Member Program Claim Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	10-10068a	Camp Lejeune Family Member Program Claim Form	10-10068a_CLFM_Claim_Form_508.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,629

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	17,919	17,919
Annual IC Time Burden (Hours)	4,480	4,480
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.