Medical Travel Refund Request

ICR 202008-1240-070

OMB: 1240-0037

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2020-10-21
Supplementary Document
2020-02-20
Justification for No Material/Nonsubstantive Change
2020-02-20
Supplementary Document
2013-06-05
Supplementary Document
2013-06-05
Supplementary Document
2013-06-05
Supporting Statement A
2018-05-11
IC Document Collections
IC ID
Document
Title
Status
38444 Modified
ICR Details
1240-0037 202008-1240-070
Active 202002-1240-012
DOL/OWCP
Medical Travel Refund Request
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 10/22/2020
Retrieve Notice of Action (NOA) 10/22/2020
  Inventory as of this Action Requested Previously Approved
06/30/2021 06/30/2021 06/30/2021
333,528 0 333,528
55,366 0 55,366
173,435 0 173,435

Requesting address change to OWCP-957 form. This form is used to request reimbursement for out-of-pocket expenses incurred when traveling to medical providers for covered medical testing or treatment.

US Code: 30 USC 901 Name of Law: Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 5 USC 8101 Name of Law: Federal Employees' Compensation Act (FECA)
  
None

1240-AA11 Final or interim final rulemaking 83 FR 27690 06/14/2018

  81 FR 73142 10/24/2016
81 FR 95649 12/28/2016
No

1
IC Title Form No. Form Name
Medical Travel Refund Request OWCP-957 Medical Travel Refund Request

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 333,528 333,528 0 0 0 0
Annual Time Burden (Hours) 55,366 55,366 0 0 0 0
Annual Cost Burden (Dollars) 173,435 173,435 0 0 0 0
No
No

$1,511,637
No
    Yes
    Yes
No
No
No
No
Anjanette Suggs 202 354-9660 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/22/2020


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