Information Collection

Form B 42 CFR Part 83.9

IC 180183 under ICR 201606-0920-010 · OMB 0920-0639.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Document Name Document Type
Form B 42 CFR Part 83.9 Form
Form B Attachment D SEC Form B.docx Form
Attachment D1 SEC Form B Instructions.rev 2.pdf Attachment D1 Form B instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form B 42 CFR Part 83.9	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Form B	Attachment D SEC Form B.docx		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program	FR Citation: 68 FR 55962

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5	-3	8
Annual IC Time Burden (Hours)	25	-15	40
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D1 Form B instructions	Attachment D1 SEC Form B Instructions.rev 2.pdf	07/14/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.