Information Collection

Authorization Form on behalf of Claimant under 42 CFR 83.7

IC 180186 under ICR 202211-0920-005 · OMB 0920-0639.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0639 can be found here:

Documents and Forms

Document Name Document Type
Authorization Form on behalf of Claimant under 42 CFR 83.7 Form and Instruction
Authorization for Individual or Entity to Petition HHS o Attachment E Authorization Form 2019_09_20.pdf Form and Instruction
Authorization for Individual or Entity to Petition HHS o Attachment E Authorization Form 2019_09_20.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization Form on behalf of Claimant under 42 CFR 83.7	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 83.7

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Authorization for Individual or Entity to Petition HHS on Behalf of a Class of Energy Employees for Addition to the Special Exposure Cohort	Attachment E Authorization Form 2019_09_20.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program	FR Citation: 68 FR 55962

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	1	1

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.