Request for State or Federal Workers' Compensation Information

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.