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