Information Collection

Disclosure of Medical Evidence

IC 216185 under ICR 202502-1240-006 · OMB 1240-0054.

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Information Collection (IC) Details

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IC Title:	Disclosure of Medical Evidence	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 725.413

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 67 FR 16869

Number of Respondents: 6,797	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,797	692	6,105
Annual IC Time Burden (Hours)	1,135	117	1,018
Annual IC Cost Burden (Dollars)	16,041	5,296	10,745

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

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