Voluntary Demographic Survey for Office of Workers' Compensation Programs (OWCP) Claimants

Voluntary Demographic Survey for Office of Workers’ Compensation Programs (OWCP) Claimants

Documents and Forms

Document Name Document Type
Form CM-411 Voluntary Demographic Survey for Office of Workers' Compensation Programs (OWCP) Claimants Form
CM-411 Voluntary Demographic Survey for Office of Workers’ Comp Voluntary Demographic Information Form Final BL_NMH.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
CM-411 Voluntary Demographic Survey for Office of Workers’ Comp Voluntary Demographic Information Form Final BL_NMH.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

IC Title:	Voluntary Demographic Survey for Office of Workers' Compensation Programs (OWCP) Claimants	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CM-411	Voluntary Demographic Survey for Office of Workers’ Compensation Programs (OWCP) Claimants	Voluntary Demographic Information Form Final BL_NMH.pdf	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 81 FR 25765

Number of Respondents: 18,077	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	18,077	18,077
Annual IC Time Burden (Hours)	1,506	1,506
Annual IC Cost Burden (Dollars)	3,127	3,127

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.