Information Collection

Electronic Records Express Submission

IC 272282 under ICR 202105-0960-009 · OMB 0960-0292.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-4631 Claimant's Recent Medical Treatment Electronic Records Express Submission	Form
HA-4631 Claimant's Recent Medical Treatment HA-4631 (revised).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	HA-4631				Yes	Yes	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 249,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	249,000	249,000
Annual IC Time Burden (Hours)	124,500	124,500
Annual IC Cost Burden (Dollars)	0	0

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.

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