Information Collection

EE 5A - Supplemental Employment Evidence

IC 251535 under ICR 202109-1240-002 · OMB 1240-0002.

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IC Title:

EE 5A - Supplemental Employment Evidence

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 30.112

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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/OWCP-11

FR Citation: 81 FR 25868

Number of Respondents: 773

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	773	773
Annual IC Time Burden (Hours)	387	387
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.