Authorized Representative Form

Request for External Review

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form OPM 1841 Authorized Representative Form Form and Instruction
OPM 1841 External Review Authorized Representative Form opm1841.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Authorized Representative Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	OPM 1841	External Review Authorized Representative Form	opm1841.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: OPM Central 19	FR Citation: 78 FR 65011

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.