Information Collection

Rehabilitation Maintenance Certificate

IC 43809 under ICR 202110-1240-001 · OMB 1240-0012.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0012 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-17 Rehabilitation Maintenance Certificate	Form
OWCP-17 Rehabilitation Maintenance Certificate owcp-17.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form
OWCP-17 Rehabilitation Maintenance Certificate owcp-17.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form

IC Title:

Rehabilitation Maintenance Certificate

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	OWCP-17	Rehabilitation Maintenance Certificate	owcp-17.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: DOL/GOVT-1 (FECA); DOL/OWCP-3; DOL/OWCP-4 (Longshore)

FR Citation: 81 FR 47418

Number of Respondents: 370

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	Previously Approved
Annual Number of Responses for this IC	3,452	3,452
Annual IC Time Burden (Hours)	575	575
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.