Information Collection

Authorized Representative Form

IC 210151 under ICR 201712-3206-004 · OMB 3206-0263.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OPM 1841 External Review Authorized Representative Form Authorized Representative Form	Form and Instruction
OPM 1841 External Review Authorized Representative Form opm1841.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

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 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 %

table that charts list of burden
	Approved	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

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.