Claim for Medical Reimbursement Form

Claim for Medical Reimbursement Form

OMB: 1240-0007

IC ID: 38473

Information Collection (IC) Details

View Information Collection (IC)

Claim for Medical Reimbursement Form
 
No Modified
 
Voluntary
 
20 CFR 30.702 20 CFR 725.701 20 CFR 10.802 20 CFR 725.705

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-915 Claim for Medical Reimbursement OWCP-915 Expires 9-30-2019.pdf http://www.dol.gov/esa/owcp/dfec/regs/complince/owcp-915.pdf Yes No Fillable Printable

Health Health Care Services

DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)  67 FR 16826

10,260 0
   
Individuals or Households
 
   0 %

  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 34,564 0 0 -3,916 0 38,480
Annual IC Time Burden (Hours) 5,738 0 0 -650 0 6,388
Annual IC Cost Burden (Dollars) 59,450 0 0 -9,429 0 68,879

Title Document Date Uploaded
FECA 20 CFR10.802 FECA 20 CFR 10.802.pdf 10/24/2012
EEOICPA 20 CFR 30.702 EEOICPA 30 CFR 30.702.pdf 10/24/2012
BLBA 20 CFR 725.701 and 20 CFR 725.705 BLBA 20 CFR 725.701 and 725.705.pdf 10/24/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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