Information Collection

Petitioner Appealing Final Decision under 42 CFR 83.18

IC 180185 under ICR 201909-0920-003 · OMB 0920-0639.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Document Name Document Type
Attachment D3 example of request for review.pdf Other-Example Request for Review

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Petitioner Appealing Final Decision under 42 CFR 83.18	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 83.18

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Example Request for Review			Attachment D3 example of request for review.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program	FR Citation: 68 FR 55962

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2	0	2
Annual IC Time Burden (Hours)	10	0	10
Annual IC Cost Burden (Dollars)	73	73	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.