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Disclosure of Medical Evidence
Disclosure of Medical Evidence
OMB: 1240-0054
IC ID: 216185
OMB.report
DOL/OWCP
OMB 1240-0054
ICR 201504-1240-002
IC 216185
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0054 can be found here:
2022-06-29 - Extension without change of a currently approved collection
2019-05-31 - Extension without change 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:
Disclosure of Medical Evidence
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
20 CFR 725.413
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/ESA-6
FR Citation:
67 FR 16869
Number of Respondents:
4,074
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
4,074
0
4,074
0
0
0
Annual IC Time Burden (Hours)
679
0
679
0
0
0
Annual IC Cost Burden (Dollars)
6,681
0
6,681
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.