Information Collection

Request for State or Federal Workers' Compensation Information

IC 13703 under ICR 201911-1240-002 · OMB 1240-0032.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0032 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-905 Request for State or Federal Workers' Compensation Information	Form
CM-905 Request for State or Federal Compensation Information 20191114 CM-905 State or Workers Comp.docx www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm	Form

IC Title:

Request for State or Federal Workers' Compensation Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.535

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	CM-905	Request for State or Federal Compensation Information	20191114 CM-905 State or Workers Comp.docx	https://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: System of Records DOL/OWCP-2

FR Citation: 67 FR 16878

Number of Respondents: 6,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,000	4,000	2,000
Annual IC Time Burden (Hours)	1,500	1,000	500
Annual IC Cost Burden (Dollars)	3,480	2,480	1,000

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.