Medical Travel Refund Request

Forms and Documents

Document Name	Status
Form OWCP-957 Medical Travel Refund Request Form and Instruction	Modified
DOL ESA-49 (EEOICPA).docx Supplementary Document	2013-06-05
DOL ESA-6 (BLBA).docx Supplementary Document	2013-06-05
DOL GOVT-1 (FECA).docx Supplementary Document	2013-06-05
1240-0037 (OWCP-957) 2016.docx Supporting Statement A	2016-12-16

IC Document Collections

IC ID	Document Title	Status
38444	Medical Travel Refund Request Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0037	ICR Reference No: 201610-1240-002
Status: Historical Active	Previous ICR Reference No: 201306-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Medical Travel Refund Request
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/2017
	Date Received in OIRA: 12/28/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/28/2017
Responses	342,452	0	302,794
Time Burden (Hours)	56,849	0	50,263
Cost Burden (Dollars)	171,123	0	148,369

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Abstract: This form is used to request reimbursement for out-of-pocket expenses incurred when traveling to medical providers for covered medical testing or treatment.

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Authorizing Statute(s): 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)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73142	10/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 95649	12/28/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medical Travel Refund Request	OWCP-957	Medical Travel Refund Request

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ICR Summary of Burden

	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	342,452	302,794	0	0	39,658	0
Annual Time Burden (Hours)	56,849	50,263	0	0	6,586	0
Annual Cost Burden (Dollars)	171,123	148,369	0	0	22,754	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been an increase in the number of reimbursement requests filed for the FECA and EEOICPA programs and as a result there is an increase from 50,263 burden hours to 56,849 burden hours which is an adjustment increase of 6,586 burden hours. Also due to the increase in mailed responses the operation and maintenance cost has increased from $148,369 to $171,123 which is an adjustment of $22,754.

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Annual Cost to Federal Government: $1,537,544

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/28/2016

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