Medical Travel Refund Request

Forms and Documents

Document Name	Status
Form OWCP-957 Medical Travel Refund Request Form and Instruction	Modified
Justification - 1240-0037 OWCP-957.docx Justification for No Material/Nonsubstantive Change	2020-10-21
OWCP-957 Medical Travel Refund Request.pdf Supplementary Document	2020-02-20
Justifiction - OWCP 957.docx Justification for No Material/Nonsubstantive Change	2020-02-20
DOL ESA-49 (EEOICPA).docx Supplementary Document	2013-06-05
DOL ESA-6 (BLBA).docx Supplementary Document	2013-06-05
DOL GOVT-1 (FECA).docx Supplementary Document	2013-06-05
ICR SS 1240-0037 OWCP-957 RuleMaking.docx Supporting Statement A	2018-05-11

IC Document Collections

IC ID	Document Title	Status
38444	Medical Travel Refund Request Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0037	ICR Reference No: 202008-1240-070
Status: Active	Previous ICR Reference No: 202002-1240-012
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Medical Travel Refund Request
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/22/2020
	Date Received in OIRA: 10/22/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	06/30/2021	06/30/2021
Responses	333,528	0	333,528
Time Burden (Hours)	55,366	0	55,366
Cost Burden (Dollars)	173,435	0	173,435

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Abstract: 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.

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Authorizing Statute(s): 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)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1240-AA11	Final or interim final rulemaking	83 FR 27690	06/14/2018

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73142	10/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 95649	12/28/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,511,637

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/22/2020

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