Medical Travel Refund Request

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0037 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-957 Medical Travel Refund Request Form and Instruction
OWCP-957 Medical Travel Refund Request_ 1240-0037 Medical Travel Refund Request (OWCP-957) 3.3.2022.pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction
OWCP-957 Medical Travel Refund Request_ 1240-0037 Medical Travel Refund Request (OWCP-957) 3.3.2022.pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and www.dol.gov/esa/regs/compliance/owcp/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Travel Refund Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.701 20 CFR 725.406 20 CFR 30.404 20 CFR 10.315

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-957	Medical Travel Refund Request_	1240-0037 Medical Travel Refund Request (OWCP-957) 3.3.2022.pdf	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsforms.htm and http://www.dol.gov/esa/regs/compliance/owcp/forms.htm	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1 (FECA)	FR Citation: 81 FR 47418

Number of Respondents: 34,703	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	333,528	333,528
Annual IC Time Burden (Hours)	55,366	55,366
Annual IC Cost Burden (Dollars)	193,446	193,446

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.