Intake Form

Request for External Review

OMB: 3206-0263

IC ID: 210150

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Intake Form
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OPM 1840 External Review Intake Form opm1840.pdf Yes Yes Fillable Fileable

Health Health Care Services

OPM Central 19  78 FR 65011

800 0
   
Individuals or Households
 
   100 %

  Approved 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 800 0 0 0 800 0
Annual IC Time Burden (Hours) 800 0 0 0 800 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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