Information Collection

Claim for Medical Reimbursement Form

IC 38473 under ICR 202404-1240-007 · OMB 1240-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-915 Claim for Medical Reimbursement Form	Form and Instruction
OWCP-915 Claim for Medical Reimbursement 1240-0007 Claim for Medical Reimbursement (OWCP-915) 2024.pdf owcpmed.dol.gov/	Form and Instruction
OWCP-915 Claim for Medical Reimbursement 1240-0007 Claim for Medical Reimbursement (OWCP-915) 2024.pdf owcpmed.dol.gov/	Form and Instruction
FECA 20 CFR 10.802.pdf FECA 20 CFR10.802	IC Document
FECA 20 CFR 10.802.pdf FECA 20 CFR10.802	IC Document
EEOICPA 30 CFR 30.702.pdf EEOICPA 20 CFR 30.702	IC Document
EEOICPA 30 CFR 30.702.pdf EEOICPA 20 CFR 30.702	IC Document
BLBA 20 CFR 725.701 and 725.705.pdf BLBA 20 CFR 725.701 and 20 CFR 725.705	IC Document
BLBA 20 CFR 725.701 and 725.705.pdf BLBA 20 CFR 725.701 and 20 CFR 725.705	IC Document

IC Title:

Claim for Medical Reimbursement Form

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 30.702 20 CFR 725.701 20 CFR 10.802 20 CFR 725.705

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-915	Claim for Medical Reimbursement	1240-0007 Claim for Medical Reimbursement (OWCP-915) 2024.pdf	https://owcpmed.dol.gov/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1 (FECA); DOL/OWCP-2 (BLBA); DOL/OWCP-11 (EEOICPA)

FR Citation: 81 FR 25766

Number of Respondents: 54,067

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 3 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	54,067	19,503	34,564
Annual IC Time Burden (Hours)	9,029	3,291	5,738
Annual IC Cost Burden (Dollars)	1,184	-58,266	59,450

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.