Information Collection Request

RegInfo.gov Technical Difficulties focusMethod = function getFocus() { document.getElementById("main").focus(); } .skip-main { border-color: transparent; background-color: transparent; left: 250px; top:75px; width:1px; height:1px; color:black; overflow:hid

ICR 202010-0960-011 · OMB 0960-0247 · RegInfo.gov Technical Difficulties focusMethod = function getFocus() { document.getElementById("main").focus(); } .skip-main { b

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0960-0247 can be found here:

2025-01-21 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document	Type	Status	Availability
Supporting Statement - 0247.docx	Supporting Statement A	Uploaded 2021-01-28	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9165	Workers' Compensation/Public Disability Benefit Questionnaire	Other-Inernal Intranet Screens	Modified

ICR Details

Status	RegInfo.gov Technical Difficulties focusMethod = function getFocus() { document.getElementById("main").focus(); } .skip-main { b
Agency/Subagency	RegInfo.gov Technical Difficulties focusMethod =
OMB Control No	0960-0247
Type of Information Collection	RegInfo.gov Technical Difficulties focusMethod = function getFocus() { document.getElementById("main").focus(); } .skip-main { b
Previous ICR Reference No	RegInfo.gov Technical Difficulties focusMethod =
Agency Tracking No	RegInfo.gov Technical Difficulties focusMethod =
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31