Medical Travel Refund Request

Medical Travel Refund Request

OMB: 1240-0037

IC ID: 38444

Information Collection (IC) Details

View Information Collection (IC)

Medical Travel Refund Request
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.701 20 CFR 725.406 20 CFR 30.404 20 CFR 10.315

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).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

Health Health Care Services

DOL/GOVT-1 (FECA)  81 FR 47418

34,703 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 333,528 0 0 0 0 333,528
Annual IC Time Burden (Hours) 55,366 0 0 0 0 55,366
Annual IC Cost Burden (Dollars) 193,446 0 0 0 0 193,446

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