Information Collection

Electronic Records Express Submission

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Electronic Records Express Submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-4631	Claimant's Recent Medical Treatment	HA-4631 (revised).pdf		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 %

	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

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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