Information Collection

Intake Form

IC 210150 under ICR 201711-3206-006 · OMB 3206-0263.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0263 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OPM 1840 Intake Form	Form and Instruction
OPM 1840 External Review Intake Form opm1840.pdf	Form and Instruction

IC Title:

Intake Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: OPM Central 19

FR Citation: 78 FR 65011

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.