Medical Travel Refund Request

ICR 202206-1240-001

OMB: 1240-0037

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2022-06-10
Supporting Statement A
2022-03-04
Justification for No Material/Nonsubstantive Change
2022-03-02
Supplementary Document
2021-04-30
Supplementary Document
2021-04-30
Supplementary Document
2021-04-30
Supplementary Document
2013-06-05
Supplementary Document
2013-06-05
Supplementary Document
2013-06-05
IC Document Collections
IC ID
Document
Title
Status
38444 Modified
ICR Details
1240-0037 202206-1240-001
Received in OIRA 202203-1240-001
DOL/OWCP
Medical Travel Refund Request
No material or nonsubstantive change to a currently approved collection   No
Regular 06/10/2022
  Requested Previously Approved
06/30/2024 06/30/2024
333,528 333,528
55,366 55,366
193,446 193,446

OWCP must reimburse beneficiaries for travel expenses for covered medical treatment. In order to determine whether amounts requested as travel expenses are appropriate, OWCP must receive certain data elements, including the signature of the physician for medical expenses claimed under the BLBA. Form OWCP-957 is the standard format for the collection of these data elements. The regulations implementing these three statutes allow for the collection of information needed to enable OWCP to determine if reimbursement requests for travel expenses should be paid. This Nonsubtantive/No material request is being submitted in order to update the toll-free telephone number for the DCMWC and the DEEOIC.

US Code: 42 USC 7384 Name of Law: Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 5 USC 8101 Name of Law: Federal Employees' Compensation Act (FECA)
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act (BLBA)
  
None

Not associated with rulemaking

  86 FR 8805 02/09/2021
86 FR 23431 05/03/2021
No

1
IC Title Form No. Form Name
Medical Travel Refund Request OWCP-957 Medical Travel Refund Request_

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 333,528 333,528 0 0 0 0
Annual Time Burden (Hours) 55,366 55,366 0 0 0 0
Annual Cost Burden (Dollars) 193,446 193,446 0 0 0 0
No
No

$1,511,637
No
    Yes
    Yes
No
No
No
No
Anjanette Suggs 202 354-9660 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/10/2022


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